THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


Insomnia  and  Nerve  Strain 


By 
Henry  S.  Upson,  M.D. 

Professor  of  Diseases  of  the  Nervous  System  in  the  Western  Reserve 
University,  Attending  Neurologist  to  the  Lakeside 
Hospital,  Cleveland,  Ohio 


/   &&&>$ 
With  Skiagraphic  Illustrations 


G.    P.   Putnam's   Sons 

New    York    and    London 

Gbe  "Knickerbocker  press 

1908 


COPYRIGHT,  1908 

.  BY 

HENRY  S.  UPSON 


•Cbe  Knicfcerbocher  press,  "Hew 


r 


A  truth — four  columns  tottering, 
The  more  with  each  successive  brick,  until 
The  key  is  added,  then,  foursquare  and  strong, 
The  world  may  rest  on  it. 


iii 


PREFACE 

A  MONO  the  insanities  some  groups  due 
**  to  changes  in  the  organ  of  the  mind 
are  understood  in  course  and  nature. 
Others,  called  psychoses,  aberrations  that 
come  alike  to  young  and  old,  mysterious 
legacies,  have  all  the  terrors  that  attach 
to  mystery  and  occur  in  forms  of  strange 
and  violent  contrast.  Their  ultimate 
cause  is  unknown;  they  are  precipitated 
by  physical  and  mental  shocks  and  in- 
juries varied  in  circumstance  and  fantas- 
tic and  deplorable  in  their  effects.  Why 
these  several  causes  should  have  one 
result,  and  results  at  times  so  varied  be 
capable  of  springing  from  one  cause  is 
a  question  whose  solution  might  carry 
with  it  chances  of  prevention  and  cure. 

The  test  of  a  theory  is  its  ability  to 
explain  observed  facts.  To  fully  prove  a 
hypothesis  all  useful  observations  should 
be  made  and  sifted,  including  those  facts 


vi  Preface 

not  previously  observed  because  too 
familiar.  The  mass  of  these  at  times 
outweighs  the  other.  An  adequate  the- 
ory should  explain  the  origin  of  psychoses 
in  these  diverse  and  distant  ways,  make 
of  the  fantastic  deeds  and  mad  fancies 
of  these  unfortunates  simple  reactions 
to  causes  such  as  influence  the  lives  of 
other  men,  and  render  definite  the  nature 
of  such  an  undesirable  heritage  and  the 
way  of  its  transmission. 

The  present  record  was  at  first  intended 
as  in  the  main  a  contribution  to  observed 
facts.  Circumstances  have  made  of  it 
an  attempt  at  an  interpretation  of  more 
familiar  facts  of  wider  range,  with  a  few 
observations  in  the  part  of  the  field  which 
happened  at  the  time  to  be  more  nearly 
in  the  author's  view. 

It  is  useless  to  cherish  illusions  with  re- 
gard to  the  present  attitude  of  the  med- 
ical profession  and  the  public  toward 
the  psychoses.  It  is  almost  Mahometan 
fatalism.  The  neuroses  are  often  curable 
by  mental  measures,  the  domination  of 
the  body  by  the  mind,  but  even  medieval 


Preface  vii 

sages  and  astrologers  wasted  few  formu- 
las over  cases  of  insanity.  The  psycho- 
ses are  a  stone  wall  against  which  the 
waves  of  psychotherapy  beat  in  vain. 
At  most  they  wear  away  a  little  of  the 
soft  porous  rock  of  the  mildest  of  them. 
Hence  the  deplorable  fact  that  so  soon 
as  a  case  is  diagnosed  as  mania,  melan- 
cholia or  dementia  precox,  the  patient 
is  housed  in  an  asylum,  or  at  the  very 
best,  fed  and  tended  by  some  loving  rela- 
tive, pending  the  execution  of  nature's 
sentence. 

The  doom  of  the  patient  lies  inherent 
in  the  definition  of  his  malady.  So 
long  as  a  psychosis  is  to  the  physician 
a  disease  without  a  lesion,  sufferers  from 
that  dread  malady  offline  soul  will  be 
given  care  with  practically  no  treatment, 
pity  with  practically  no  hope. 

No  apology,  then,  is  necessary  for  any 
attempt  to  look  behind  the  veil.  It  hides 
disease  so  hopeless  that  from  the  more 
dread  form,  dementia,  fewer  of  those 
afflicted  recover,  in  spite  of  all  that  love 
and  skill  can  do,  than  of  sufferers  from 


viii  Preface 

consumption  or  cancer  or  the  black 
plague  itself.  Those  who  do  not  recover 
are  found  in  our  asylums,  largely  peopled 
with  these  unfortunates. 

No  attempt  is  made  in  this  small  work 
to  collocate  the  material  available  for  a 
study  of  the  psychoses.  Two  objects  only 
have  been  kept  in  view;  to  put  on  record  a 
few  observations  as  material  for  the  recon- 
struction of  a  column  long  since  fallen  and 
neglected  by  recent  workers  in  this  field, 
and  in  what  measure  may  now  be  feasible 
to  supply  that  most  solid  of  all  building 
materials,  a  working  theory  to  bind  the 
swaying  fabric  of  the  structure. 


CONTENTS 


PAGE 


PRELIMINARY         .....  i 
ILLUSTRATIVE  CASES       .         .         .         .12 

SLEEP  AND  FATIGUE       ....  44 

THE  EMOTIONS       .....  48 

SUBCONSCIOUS  SENSORY  REFLEXES  .          .  57 

ATAVISTIC  SYMPTOMS      ....  63 

DERANGEMENTS  OP  FORMAL  THOUGHT      .  66 

INDUCTIVE  INHIBITION    ....  70 

CONVULSIVE      SEIZURES     AND     CHOREIC 

SPASM    ......  72 

VASCULAR  POTENTIAL     ....  84 

MECHANISM       OF       THE      VASO-NEURAL 

CIRCUIT           .....  94 

NUTRITION  AND  VITALITY        ...  98 
CELL  POTENTIAL  IN  EVOLUTION       .         .102 

EPICRITICJsfBURO-PsYCHOSES  .                            .  10$ 


x  Contents 

PACK 

PROGNOSIS m 

THERAPY       .          .                   .         .         .  114 

PREDISPOSITION   AND   HEREDITY      .         .  125 

APPENDIX: 

DENTAL  LESIONS     ....  131 

TECHNIQUE  OF  DENTAL  SKIAGRAPHY  139 


ILLUSTRATIONS 


FACING 
PACK 


CASE  5. — Melancholia.    Impacted  upper  left 
third  molar         .          .          .          .          .14 

CASE  14. — Hysteria.     Impacted  lower  left 
third  molar          .          .          .          ...        14 

CASE  15. — Acute  Mania.     Impacted  cuspid 
tooth          .          .          .          .          .          .14 

CASE  1 6. — Incipient  Dementia  Precox.    Im- 
paction  of  all  of  the  wisdom  teeth         .        14 

CASE  1 8. — Dementia  precox.    Impaction  of 
a  lateral  incisor  and  all  four  wisdom  teeth      38 

CASE  1 8. — Dementia  precox.     Upper  right 
third  molar          .          .          .          .  38 

CASE    22. — Mania.     Impacted  lower  third 
molar          ......       38 

xi 


xii  Illustrations 


FACING 
PACK 


Case  of  profound  melancholia,  with  subcon- 
scious sensory  reflex  in  upper  incisor  teeth. 
Impaction  of  upper  third  molar.  38 

Impacted  upper  fourth  molar  tooth  .          .38 

CASE  2. — Insomnia.  Alveolar  abscess.  Lower 
molar  tooth.    Roots  partly  absorbed       .     132 

CASE  3. — Renal  and  Vascular  Disease.  Mul- 
tiple abscesses  in  both  upper  and  lower 
jaws  .  .  .  .  .  .  132 

CASE  4. — Melancholy.  Alveolar  abscess. 
Molar  tooth.  Roots  partly  absorbed  .  132 

Case  of  Albuminuria  with  cardiac  and  vas- 
cular symptoms.    Complete  nervous  break- 
down of  five  years'  standing.     Multiple 
abscesses  in  both  upper  and  lower  jaws   .     132 

Position  for  upper  right  molar  region.    Tube 
and  film  should  be  placed  well  back.  (Dr. 
Lodge.)      ......     142 

(First.) 

Position  for  lower  right  molar  region.    (Dr. 
Lodge.)      ......     142 

(Second.) 


Illustrations  xiii 


FACING 

PACK 


Position  for  upper  incisors.     (Dr.  Lodge.)       142 
(Third.) 

Position  for  lower  incisors.     (Dr.  Lodge.)       142 
(Fourth.) 


INSOMNIA 
AND   NERVE  STRAIN 


\\  HTH  regard  to  the  nature  of  the 
pathologic  processes  underlying 
painful  and  other  functional  nervous  and 
mental  disorders,  authorities  are  at  the 
present  day  practically  unanimous  in  as- 
cribing them  either  to  those  most  misty 
of  all  indefinite  conditions,  nervousness, 
hysteria,  and  autosuggestion,  or  to  toxins 
of  unknown  origin  and  uncertain  nature. 

PHYSICAL     CAUSES     OF     INSANITY.— 
Among  the  physical  causes  of  insanity 
diseases  of  viscera  other  than  the  brain 
formerly   held   a   prominent   place,   the 


2       Insomnia  and  Nerve  Strain 

mind  and  the  soul  in  medieval  thought 
being  considered  to  reside  in  the  entrails. 
With  the  growing  realization  of  the  im- 
portance of  the  brain  as  the  soul  and 
mind  organ,  the  tendency  gained  ground 
to  regard  insanity  as  a  brain  disease,  and 
to  limit  its  causes  to  psychic  shocks  and 
brain  lesions.  In  spite  of  this  fact  dis- 
eases of  many  of  the  viscera  have 
held  their  place,  although  a  subor- 
dinate one,  even  in  the  text-books  of 
to-day. 

Patients  affected  with  phthisis  and 
with  heart  disease  in  their  late  stages, 
have  long  been  known  to  become  in 
some  instances  the  victims  of  atypical 
psychoses.  Affections  of  the  digestive  sys- 
tem and  of  the  pelvic  organs  are  recog- 
nized as  more  frequent  causes  of  insanity, 
and  the  kidneys  and  liver,  thyroid  gland, 
and  practically  all  of  the  other  viscera 
are  known  to  be  the  occasional  seat  of 
changes  which  cause  mental  alienation. 
Many  cases  recently  described  by  Suck- 
ling, of  London,  show  the  importance 
of  movable  kidney  as  a  cause  of  various 


Preliminary  3 

forms  of  insanity,  especially  mania  and 
melancholia. 

DENTAL  DISEASE. — Cases  long  ago 
reported  were  regarded  as  showing  that 
even  disorders  of  the  teeth  might  in  rare 
instances  cause  insanity,  and  early  in  the 
nineteenth  century  Esquirol,  the  great 
French  alienist,  stated  that  the  first 
dentition  by  causing  convulsions  in  chil- 
dren predisposes  to  insanity,  and  that 
tardy  appearance  of  the  teeth  sometimes 
causes  it. 

In  1876  the  English  alienist,  Savage, 
reported  a  number  of  cases  of  insanity 
terminating  by  acute  illness ;  among  them 
that  of  a  man  of  twenty-two,  of  bad 
heredity,  who  became  maniacal,  rode 
madly  about  the  country,  was  unmanage- 
able, and  brought  to  the  asylum.  After 
three  or  four  months  he  developed  a 
severe  toothache  which  he  endured  for  a 
few  days  and  the  tooth  was  then  pulled. 
There  was  pus  at  the  ends  of  the  roots. 
The  patient  recovered  promptly  from  his 
mania.  Another  patient  reported  by 


4       Insomnia  and  Nerve  Strain 

Savage  recovered  from  mania  after  the 
development  and  evacuation  of  an 
alveolar  abscess.  These  are  mentioned 
by  Lauder  Brunton  in  an  essay  as  cases 
of  insanity  due  to  diseased  teeth. 

Similar  cases  have  been  reported  from 
time  to  time,  and  lesions  of  the  teeth  find 
occasional  mention  in  some  of  the  older 
text-books  of  mental  disease.  Dental 
works  still  speak  of  insanity  and  many 
other  functional  nervous  disorders  as 
occasionally  due  to  dental  lesions.  Mod- 
ern psychiatry  takes  no  account  of  these 
scattered  cases,  and  I  am  not  aware  that 
any  one  has  ever  looked  for  dental  dis- 
ease as  a  cause  of  insanity,  or  attempted 
a  cure  by  its  eradication. 

There  seems  to  exist  among  physicians 
not  only  a  disregard  but  a  distinct  though 
mild  dislike  of  the  teeth  as  organs  to  be 
reckoned  with  medically,  they  being  as 
it  were  an  Ishmael,  not  to  be  admitted 
to  their  pathologic  birthright.  Lauder 
Brunt  on 's  essay  on  the  subject  is  too 
little  known  and  heeded,  and  few  such 


Preliminary  5 

systematic  attempts  have  been  made  to 
correlate  their  disorders  with  the  suffer- 
ings of  the  human  race,  except  for  the 
most  obvious  phenomena  of  pain.  Ordi- 
nary pain  at  a  distance,  as  headache  or 
neuralgia  due  to  the  teeth,  though  well 
known  is  commonly  disregarded.  Even 
the  various  reflex  nervous  phenomena 
in  children,  convulsions,  fretfulness,  and 
fever,  are  not  now  ascribed  to  the  irrita- 
tion either  of  teething  or  of  dental  caries, 
but  to  digestive  disorders.  The  state 
of  recent  opinion  as  enshrined  in  epigram 
is  that  the  result  of  teething  is  nothing  but 
teeth. 

DISSOCIATION  OF  SYMPTOMS. — The 
present  attempt  at  a  study  of  the  sensory 
phenomena  of  dental  lesions  had  its  fons 
et  origo  in  an  observation  made  in  a  case 
of  ordinary  toothache  that  the  depression 
and  insomnia  did  not  vary  in  direct  ratio 
with  the  pain,  but  were  sometimes 
marked  when  the  local  pain  was  slight. 
The  symptoms  being  thus  discovered  to 
be  dissociated  phenomena,  the  disjecta 


6       Insomnia  and  Nerve  Strain 

membra  of  a  symptom  complex,  a  pro- 
visional theory  was  formed  subject  to 
correction  by  further  study,  that  tooth- 
ache is  no  more  the  cause  of  insomnia 
than  is  this  the  cause  of  the  ache,  but  that 
both  are  in  equally  direct  dependence  on 
the  dental  lesion.  In  view  of  the  possi- 
bilities thus  raised  the  demonstration  of 
the  independence  of  all  the  concomitant 
symptoms  of  dental  lesions  seemed  to 
acquire  importance,  and  an  investigation 
was  entered  upon,  at  first  of  cases  of  mel- 
ancholia, and  later  of  mania  and  dementia 
precox,  with  this  point  in  view. 

INCIDENCE  OF  DENTAL  LESIONS. — The 
occurrence  of  the  commoner  lesions,  caries 
and  abscess,  can  hardly  be  considered  to 
have  much  significance  without  a  study 
of  the  effect  of  their  removal  on  the  course 
of  the  disease.  It  was  early  apparent 
that  a  rarer  condition,  dental  impaction, 
was  relatively  common  in  these  patients. 
Of  about  fifty-two  cases  examined  in  the 
Cleveland,  Massillon,  and  Columbus  State 
Hospitals,  through  the  courtesy  of  their 


Preliminary  7 

respective  superintendents,  twenty-five 
patients  were  suffering  from  impacted 
teeth,  many  of  them  having  several 
lesions  of  this  kind. 

To  make  a  test  of  the  ultimate  value 
of  the  relief  of  this  condition,  on  patients 
insane,  many  of  them  for  long  periods, 
and  many  demented,  must  be  the  work 
of  some  years.  Meanwhile  the  cases  seen 
in  private  practice,  most  of  them  of 
shorter  duration,  many  suffering  from 
the  milder  dental  lesions,  have  presented 
some  points  of  interest  and  have  seemed 
worthy  of  collocation  with  cases,  seen  dur- 
ing the  past  fifteen  years,  of  neuroses  and 
psychoses  due  to  disease  of  other  viscera. 
The  surprisingly  frequent  dental  irrita- 
tions in  a  way  supplement  these  others, 
and  stop  a  gap  both  diagnostic  and  thera- 
peutic in  the  study  of  the  nervous  results 
of  visceral  lesions.  To  this  fact  is  largely 
owing  what  may  seem  an  undue  prepon- 
derance in  number  of  dental  cases  cited. 

The  main  theme  of  the  present  work  is 
a  provisional  sketch  of  the  mode  of  origin 
of  the  psychoses.  An  early  presentation 


8       Insomnia  and  Nerve  Strain 

is  made  in  the  hope  that  others  may  be 
induced  to  consider  the  field  a  promising 
one  for  further  study. 

HEAD'S  RESEARCHES. — It  is  necessary 
first  to  consider  the  general  features  of 
the  sensory  system  in  order  to  appreciate 
the  possibilities  of  the  genesis  in  it  of 
emotional  and  mental  disease.  Fortu- 
nately the  study  of  the  afferent  nervous 
system  published  by  Head,  Rivers,  and 
Sherren  in  Brain,  November,  1905,  renders 
this  possible. 

In  order  to  make  a  thorough  investiga- 
tion of  conditions  in  the  parts  of  the  skin 
supplied  by  peripheral  nerves,  Dr.  Head 
caused  the  radial  and  external  cutaneous 
nerves  to  be  divided  in  the  neighborhood 
of  his  own  hand  and  elbow  and  after- 
wards subjected  his  arm  and  hand  to  sys- 
tematic examinations.  The  result  was 
the  discovery  of  three  distinct  forms  of 
sensibility,  the  first  of  which  he  calls  deep 
sensibility,  supplied  to  the  deeper  struc- 
tures by  afferent  fibres  running  with  the 
motor  nerves.  The  result  of  pressure  is 


Preliminary  9 

pain  which  is  fairly  accurately  localized. 
This  function  persists  after  the  cutaneous 
nerves  of  a  part  have  been  thoroughly 
divided. 

The  skin  is  found  to  possess  two  forms 
of  sensibility,  one  the  epicritic,  by  which 
one  appreciates  light  touches  localized 
with  considerable  accuracy,  and  impres- 
sions of  warmth  and  coolness. 

The  other  form  of  sensibility  is  called 
by  Head  protopathic.  It  is  deeper  in  lo- 
cation than  epicritic  sensibility,  not  being 
evoked  by  light  touches  but  by  compara- 
tively deep  pin-pricks  or  by  heat  or  cold 
or  touching  or  pulling  hairs.  It  is  peculiar 
in  giving  a  sensation  that  when  intense 
is  a  distinct  pain,  not  well  denned  but 
widespread  and  radiating.  When  located 
it  may  not  be  at  the  point  stimulated  but 
at  some  distance. 

Protopathic  sensibility  is  recovered 
sooner  than  is  the  epicritic  variety,  and 
with  this  recovery  trophic  changes  con- 
sequent on  division  of  the  nerves  disap- 
pear. Recovery  of  protopathic  function 


io     Insomnia  and  Nerve  Strain 

in  Head  occurred  in  seven  weeks,  and 
was  complete  in  twenty-nine  weeks, 
while  the  epicritic  fibres  were  not  fully 
restored  a  year  after  the  operation. 

After  the  protopathic  fibres  had  re- 
covered their  function  and  while  epicritic 
sensibility  was  still  lacking,  it  required 
a  stronger  stimulus  than  normal  to  cause 
pain,  but  the  response  was  excessive  and 
was  accompanied  by  an  irresistible  im- 
pulse to  draw  the  hand  away.  This 
indicates  a  certain  amount  of  control 
of  the  protopathic  by  the  epicritic  sys- 
tem. 

VISCERAL  SENSIBILITY. — Sensibility  of 
the  viscera  corresponds  very  closely  with 
that  supplied  by  the  protopathic  system 
to  the  skin.  Their  nerve-supply  must  be 
regarded  as  a  part  of  the  same  mechan- 
ism. Head  found  that  heat  and  cold, 
when  applied  within  the  walls  of  the  in- 
testines, were  said  by  patients  to  be  un- 
comfortable, but  the  sensation  was  never 
localized  in  the  abdomen.  They  gave  a 
burning  or  cold  feeling,  sometimes  on  the 


Preliminary  1 1 

skin  and  sometimes  in  the  air  entirely 
outside  the  patient's  body. 

In  the  viscera  deep  sensibility  seems 
to  be  subserved  by  the  end-organs  of 
Pacini  and  probably  gives  some  indication 
of  movement  and  position. 

It  is  evident  from  Head's  researches 
that  the  epicritic  system  is  mainly  con- 
cerned with  localization  and  the  represen- 
tation of  sensation  in  consciousness,  that 
is  to  say,  in  the  cortical  receiving  centres. 
The  deep  and  protopathic  systems  supply 
information  that  is  often  dim  and  may 
not  be  present  in  consciousness  at  all. 

In  investigating  the  relations  existing 
between  disorders  of  sensation  as  they 
affect  emotion  and  mentality  in  func- 
tional nervous  disease,  it  has  not  been 
possible  to  separate  the  deep  and  the 
protopathic  systems.  The  relations  of 
the  epicritic  system  with  regard  to  the 
other  two  are  more  clear,  but  throughout 
this  work  when  the  protopathic  system 
is  spoken  of  it  may  be  taken  to  include 
the  deep  system.  In  the  same  way  the 
epicritic  and  voluntary  functions  of  the 


12     Insomnia  and  Nerve  Strain 

cortex  are  distinguished  with  compara- 
tive ease  from  those  of  the  lower  centres, 
but  when  basal  ganglia  are  spoken  of  they 
are  meant  to  include  not  only  the  gangli- 
onic  masses  at  the  base  of  the  brain,  but 
the  spinal  cord  as  well. 

IRRITATIVE  THEORY  OF  THE  NEURO- 
PSYCHOSES.— The  view  here  taken  of  the 
neuroses  and  psychoses  in  general  is  that 
they  are  primarily  irritative  disorders  of 
the  sensory  system  affecting  the  remain- 
der of  the  nerve  mechanism  indirectly. 
The  irritants  are  either  mechanical  or 
toxic,  and  the  discussion  of  their  location 
and  mode  of  action  may  be  deferred  until 
later. 

ILLUSTRATIVE  CASES 

Among  the  diseases  to  which  mankind 
is  subject  dental  caries  is  probably  the 
most  common,  and  of  dental  caries  and 
other  disorders  of  the  teeth  insomnia  is, 
I  believe,  much  the  most  common  symp- 
tom, often  occurring  without  local  pain 


Illustrative  Cases  13 

or  indication  of  its  place  of  origin.  It  is 
usually  accompanied  by  other  indications 
of  disordered  nerve-action.  The  follow- 
ing case  is  among  the  more  simple  in- 
stances. 

CASE  i.  INSOMNIA. — The  patient  was 
a  young  business  man  thirty  years  of  age 
previously  in  good  health.  When  seen 
he  had  been  suffering  from  persistent 
sleeplessness  without  obvious  cause  for 
about  a  year.  He  had  been  working 
hard  but  was  under  no  financial  strain, 
and  had  simply  noticed  an  increased 
difficulty  in  going  to  sleep  and  tendency 
to  waken  after  a  few  hours.  He  drifted 
into  the  habit  of  taking  the  usual  hyp- 
notic drugs,  felt  rather  weak  and  nervous 
during  the  day,  and  was  quite  unable  to 
work.  He  was  unusually  sensitive  to 
noise  and  light. 

Skiagraphs  of  his  teeth  showed  no 
lesions  with  the  exception  of  a  number 
of  cavities,  one  of  which  affected  the 
pulp-chamber.  Convalescence  began  be- 
fore his  dental  work  was  finished  and  was 


H     Insomnia  and  Nerve  Strain 

continuous  so  that  within  a  few  weeks 
he  was  sleeping  well  without  narcotics. 

Neither  in  this  nor  in  any  other  of  the 
dental  cases  has  there  been  toothache  or 
other  localizing  symptom  referable  to  the 
teeth  except  as  noted.  ^ 

CASE  2.  INSOMNIA. — Insomnia  is  so 
constant  a  factor  in  the  life-history  of 
many  people  as  to  be  considered  consti- 
tutional. These  cases,  however,  are  on 
a  basis  of  distinct  physical  disease.  One 
patient  recently  seen,  a  man  sixty  years 
of  age,  has  for  the  last  thirty  or  thirty- 
five  years  had  more  or  less  insomnia, 
lately  consisting  of  an  early  wakening 
usually  at  about  four  o'clock.  Dur- 
ing the  earlier  years  of  his  life  he  was 
sometimes  persistently  sleepless  for  long 
periods  without  pain  or  obvious  cause. 
Skiagraphic  examination  showed  a  con- 
dition of  the  teeth  dating  back  to  a  be- 
ginning many  years  ago.  Two  of  the 
teeth  were  set  in  pus  pockets,  very  loose, 
and  had  at  times  been  ulcerated.  Two 


CASE  5. — Melancholia.     Impac- 
ted upper  left  third  molar. 


CASE  14. — Hysteria.  Impacted 
lower  left  third  molar. 


CASE  15. — Acute  Mania.    Impac- 
ted cuspid  tooth. 


Case  of  Hysteria  and  Melan- 
choly of  many  years'  standing. 
Impacted  upper  right  third  molar. 


CASE  16. — Incipient  Dementia  Precox.  Impac- 
tion  of  all  of  the  wisdom  teeth.  One  upper  and  one 
lower  impacted  tooth  are  here  shown. 


Illustrative  Cases  15 

of  the  other  teeth  had  abscesses  at  the 
roots.  The  two  teeth  most  diseased  were 
drawn  and  the  others  treated.  The  pa- 
tient has  since  been  sleeping  through  the 
night  without  wakening,  for  the  first  time 
in  many 


/  CASE  3  .  INSOMNIA  :  ARTERIAL  DISEASE. 
—One  of  the  complications  of  insomnia 
which  is  of  more  than  usual  importance 
is  arterial  disease.  Worry  and  other 
emotions  are  thought  to  create  arterial 
tension  as  an  important  factor  in  causing 
arterio-sclerosis.  The  underlying  phys- 
ical element  which  exists  in  many  such 
patients  is  illustrated  in  the  following 
case. 

A  business  man  sixty-five  years  of  age 
began  six  years  ago  to  suffer  from  insom- 
nia consequent,  apparently,  on  worry 
over  his  financial  affairs.  For  more  than 
two  years  he  suffered  from  marked  in- 
somnia and  great  mental  anxiety  and 
then  broke  down  in  health.  He  had  a 
slight  stroke  of  paralysis,  suffered  much 
with  bad  feelings  in  his  head  of  an  indefi- 


16     Insomnia  and  Nerve  Strain 

nite  character  but  without  local  pain. 
An  examination  of  his  teeth  showed  that 
they  were  in  very  bad  condition  and 
skiagraphs  revealed  multiple  abscesses 
in  both  the  upper  and  lower  jaws.  Ex- 
traction of  some  of  the  teeth  was  followed 
by  marked  relief,  but  the  case  remains 
incomplete  therapeutical!^. 

CASE  4.  MELANCHOLY. — Equally  sim- 
ple and  common  are  the  cases  of  melan- 
choly running  into  mild  melancholia  with 
somewhat  perverted  introspective  ideas 
rather  than  genuine  delusions.  Of  this 
a  typical  example  is  the  following:  A 
wealthy  man  thirty-five  years  old,  with 
no  business  cares,  has  had  for  the  last 
twelve  or  fifteen  years  occasional  attacks 
of  depression  lasting  from  two  or  three 
to  ten  or  twelve  months.  When  first 
seen  he  had  been  depressed  for  several 
months,  thought  that  he  could  not  recover 
and  considered  himself  a  nuisance  to 
his  family.  He  had  had  no  pain  of  any 
kind.  During  some  of  these  attacks  sleep 
had  been  disturbed,  but  when  seen  he 


Illustrative  Cases  1 7 

was  sleeping  well  and  had  a  fairly  good 
appetite.  Skiagraphs  showed  irritation  at 
the  roots  of  a  few  of  the  teeth  and  an 
abscess  at  the  roots  of  one  molar  tooth, 
which  was  treated  for  some  time  but 
finally  had  to  be  drawn.  He  made  a 
progressive  and  rapid  recovery. 

'  CASE  5.  INSOMNIA:  MELANCHOLY. — 
A  somewhat  whimsical  element  is  intro- 
duced into  the  following  case  by  the 
psychic  cause,  although  the  symptoms, 
except  for  their  short  continuance,  were 
of  a  much  more  serious  character. 

A  robust  mechanic  twenty-eight  years 
of  age,  three  weeks  before  he  was  first 
seen  came  home  from  his  work,  and  his 
wife  moodily  remarked  that  she  thought 
she  was  losing  her  mind.  It  immediately 
occurred  to  him  that  he  might  be  losing 
his  mind.  He  slept  little  that  night  or 
the  succeeding  nights,  gave  up  his  work 
and  spent  his  days  in  fear  of  the  asylum. 
In  brief,  tonics  and  assurances  failed  to 
relieve.  The  only  discoverable  lesion 
was  dental  caries,  and  the  filling  of  a  deep 


1 8     Insomnia  and  Nerve  Strain 

cavity  extending  into  the  pulp  was  fol- 
lowed by  prompt  recovery  and  return  to 
work.  There  had  at  no  time  been  tooth- 
ache or  other  pain,  but  dizziness  and 
sweating  had  been  noted. 

CASE  6.  INSOMNIA:  MELANCHOLIA. — 
Such  cases  as  the  above  merge  gradually 
into  typical  melancholia  of  the  profounder 
kind.  An  unmarried  woman,  twenty- 
seven  years  old,  a  teacher,  for  a  year  had 
been  profoundly  melancholy  with  in- 
tractable insomnia,  delusions  of  various 
deadly  sins,  and  entire  hopelessness  of 
recovery.  Restlessness  was  extreme, 
tonic  and  local  uterine  treatment  were 
of  no  avail.  As  a  last  resort  the  teeth 
were  examined.  They  were  apparently 
in  perfect  condition.  A  skiagraph 
showed  an  impacted  right  upper  third 
molar  tooth  pressing  against  the  second 
molar,  a  condition  obviously  capable  of 
causing  irritation.  The  symptoms,  in 
about  a  week  after  the  removal  of  the 
tooth,  began  to  improve.  Recovery  was 
complete  in  six  or  eight  weeks,  and  has 


Illustrative  Cases  19 

persisted.      There  had  been  at  no  time 
pain  or  other  localizing  symptom. 

The  investigation  of  dental  conditions 
early  in  its  course  took  more  definite 
shape  in  the  examination  of  the  third 
case  observed,  through  the  advice  given 
by  Dr.  John  F.  Stephan,  to  have  skia- 
graphs taken  of  the  teeth  in  order  to  a 
thorough  elucidation  of  the  conditions. 
The  examination  of  the  first  patient  by 
skiagraph  showed  negative  results.  The 
recovery  of  the  second  patient  took  place 
by  dental  treatment  without  skiagraphic 
examination.  In  the  third  patient,  how- 
ever, the  teeth  on  inspection  seemed  to 
be  in  unusually  good  condition  but  an 
impacted  third  molar  tooth  was  present 
and  its  removal  was  followed  by  recovery 
from  melancholia.  This  is  the  case  just 
cited  in  the  present  series. 

CASE  7.  MELANCHOLY  OF  DENTAL 
ORIGIN. — In  this  connection  Dr.  Stephan 
imparted  to  me  the  following  interesting 
observation  which  he  had  previously 


20     Insomnia  and  Nerve  Strain 

made.  A  patient  in  whom  suppuration 
was  present  at  the  roots  of  one  of  the 
teeth  was  subject  to  a  depression  which 
seemed  to  her  like  a  cloud  enveloping 
her.  On  opening  the  tooth  the  cloud 
lifted.  When  the  tooth  was  closed  there 
invariably  followed  within  about  an  hour 
a  settling  down  of  this  emotional  cloud, 
even  when  the  patient  supposed  that  the 
tooth  had  simply  been  treated  but  not 
closed.  The  result  was  invariable  on 
several  trials  so  long  as  the  abnormal 
dental  condition  persisted. 

CASE  8.  MELANCHOLIA. — Emotional 
variations  which  accompany  disorders 
of  the  abdominal  and  pelvic  viscera 
are  so  common  as  to  be  matters  of  daily 
observation.  It  is  of  special  importance 
to  realize  that  there  is  no  essential  differ- 
ence between  mild  cases  of  this  character 
and  the  severer  cases  of  melancholia  and 
mania  which,  due  to  the  same  cause, 
present  all  of  the  mental  symptoms  char- 
acteristic of  what  are  considered  true 
psychoses.  The  clinical  picture  of  agitated 


Illustrative  Cases  21 

melancholy  is,  in  my  experience,  often  met 
in  connection  with  gastric  and  intestinal 
disease.  Mild  melancholy  is  an  almost 
regular  accompaniment  of  indigestion, 
and  this  under  exceptional  conditions 
may  rise  to  a  condition  of  frenzied 
depression  with  intractable  nervousness 
and  insomnia. 

One  such  patient,  a  man  sixty-three 
years  of  age,  in  whom  the  attack  of 
mental  alienation  followed  dysentery,  re- 
sponded readily  and  rapidly  to  purgation, 
milk  diet,  and  the  salicylates,  when 
hypnotics  and  sedatives  were  powerless 
to  give  more  than  the  slightest  relief. 
In  this  case,  insomnia,  agitation,  and 
depression  were  extreme,  and  the  symp- 
tomatic diagnosis  of  melancholia  agitata 
was  amply  justified  by  the  conditions 
present. 

CASE  9.  MELANCHOLIA. — The  cause  in 
the  preceding  case  was  obviously  physical. 
In  the  following  instance  the  exciting 
cause  was  psychic,  so  purely  as  almost 
to  exclude  the  probability  of  a  physical 


22     Insomnia  and  Nerve  Strain 

basis.  The  patient  was  a  woman,  fifty- 
five  years  of  age,  fat,  florid,  and  always  in 
perfect  health.  Three  months  before  she 
was  first  seen,  her  husband  accidentally 
shot  himself  and  she  was  in  consequence 
much  alarmed  and  agitated.  The  wound 
proved  to  be  a  slight  one,  but  she  found 
herself  depressed  in  spite  of  this  fact,  and 
during  the  whole  intervening  time  until 
I  saw  her  she  was  sleepless  at  night,  heavy 
and  depressed  by  day,  and  was  firmly 
convinced  that  she  was  insane  and  would 
be  sent  to  an  asylum.  Little  could  be 
made  out  with  regard  to  the  abdominal 
organs  on  account  of  the  layer  of  fat. 
Physical  examinations  gave  negative 
results.  The  only  apparent  anomaly  was 
loss  of  appetite  with  moderate  flatulence. 
However,  on  milk  diet,  laxatives,  and  in- 
testinal antiseptics,  sleep  promptly  re- 
turned without  hypnotics,  although  these, 
even  in  rather  large  dosage,  had  previ- 
ously failed  to  relieve.  She  made  a  pro- 
gressive recovery. 

CASE  10.     MELANCHOLIA. — The  follow- 


Illustrative  Cases  23 

ing  case  is  in  appearance  simple.  Psy- 
chic shock  was  followed  by  a  digestive 
difficulty  as  the  physical  basis  of  dis- 
ordered function.  The  patient  was  a  man 
forty-two  years  of  age  who  in  general  had 
been  in  good  health.  Some  four  years 
before  he  was  seen  he  went  through  a  pe- 
riod of  business  anxieties.  He  was  also 
overworked  for  several  years  and  finally 
began  to  notice  that  he  was  unable  to 
work  as  well  as  usual.  He  became  de- 
pressed and  anxious  and  had  a  definite 
feeling  of  sinking  in  the  epigastrium.  He 
had  no  ringing  in  the  ears  or  tingling  in 
the  hands,  but  had  a  full  feeling  in  the 
head  with  more  or  less  throbbing.  No 
especial  examination  was  made  at  that 
time  for  dental  lesions  and  in  this  respect 
the  case  remains  obscure.  Periods  of 
very  great  depression  would  come  on, 
lasting  for  some  hours,  and  would  then 
pass  off,  leaving  him  comparatively  free, 
although  far  from  well.  His  paroxysms 
of  depression  were  apt  to  come  soon  after 
meals.  In  a  few  months  they  were  par- 
tially replaced  by  attacks  of  intolerable 


24     Insomnia  and  Nerve  Strain 

itching.  This  came  quite  irregularly, 
sometimes  several  times  a  day  and  some- 
times not  for  a  week  or  two.  They  lasted 
from  one  to  twenty  minutes.  His  back 
and  the  backs  of  his  hands  were  the  parts 
most  affected.  This  itching  was  at  times 
accompanied  by  a  red  rash  along  the  front 
of  the  arms,  which  was  called  urticaria  by 
the  physicians  who  saw  it.  The  patient 
describes  it  as  an  itching  which  did  not 
incline  him  to  scratch,  but  was  like  a 
prickling  sensation  as  of  needles  stuck 
through  the  skin  from  within  out.  All 
sorts  of  applications  were  powerless  to 
relieve  this  condition.  It  was  diagnosed 
as  an  affection  of  the  vaso-motor  nerves 
by  every  physician  who  saw  it.  Baths 
and  many  forms  of  medication  were  tried 
without  effect.  The  patient  was  seen  by 
many  eminent  practicians  and  special- 
ists. Meanwhile  the  continual  worry  and 
depression  were  present,  but  somewhat 
better. 

Two  years  after  the  beginning  of  the 
disease,  the  patient  himself  insisted  on  a 
chemical  examination  of  the  stomach 


Illustrative  Cases  25 

contents.  A  slight  subacidity  was  found , 
attributed  by  the  examining  physician 
to  nervous  dyspepsia.  He  prescribed 
seven  drops  of  dilute  hydrochloric  acid, 
but  said  at  the  time  that  it  would  proba- 
bly not  be  effectual  in  relieving  the  symp- 
toms. It  is  significant  that  the  attacks 
of  itching  were  always  accompanied  by 
psychic  pain,  with  a  feeling  of  tension  in 
the  frontal  region.  The  patient  would 
then  have  an  inclination  to  sleep,  and 
would  awake  feeling  much  refreshed. 

The  very  first  dose  of  hydrochloric 
acid  was  followed  by  complete  relief 
from  both  the  itching  and  the  psychic 
pain.  The  acid  was  taken  two  or  three 
times  a  day  for  six  weeks  and  ever  since 
that  time  it  has  been  taken  when  needed. 
It  is  invariably  effective  and  there  has 
never  been  a  return  of  very  severe  itching. 
Some  attacks  of  depression  have  occurred 
so  that  several  times  the  patient  has  felt 
as  if  he  might  have  to  give  up  his  work. 
On  taking  the  acid,  however,  for  a  few 
days  he  has  invariably  recovered  from 
this  feeling. 


26     Insomnia  and  Nerve  Strain 

Certain  things  have  disagreed  with 
the  patient.  He  thinks  that  sweet 
things — eggs,  milk,  and  in  general  things 
which  make  him  feel  bilious — are  to  be 
avoided.  The  patient  has  now  been  in 
good  health  for  thirteen  years. 

CASE  ii.  MELANCHOLIA. — The  follow- 
ing is  a  case  common  enough  in  its 
essential  features  but  too  often  unrecog- 
nized as  regards  the  physical  substratum. 
The  patient,  a  woman  thirty  years  of  age, 
took  up  an  amount  of  mental  work 
that  involved  moderate  overstrain.  Al- 
though at  the  time  she  was  in  unusually 
good  health,  she  soon  began  to  be  sleepless 
and  depressed,  and  developed  delusions 
that  she  was  pregnant  and  that  she  had 
committed  various  unpardonable  sins, 
and  procured  a  revolver  with  a  view  to 
committing  suicide.  When  seen  she  had 
grown  steadily  worse  for  two  or  three 
months.  She  had  the  usual  coated  tongue 
and  pallor  of  the  melancholic,  tired 
easily,  had  no  energy,  and  was  much 
occupied  with  her  delusions.  Examina- 


Illustrative  Cases  27 

tion  revealed  serious  disease  of  both 
uterus  and  ovaries.  Great  improve- 
ment in  the  mental  condition  was  appar- 
ent within  a  few  days  after  an  operation 
undertaken  to  relieve  the  pelvic  condi- 
tions. The  patient  gained  steadily  in 
strength  and  cheerfulness  for  about  a 
year,  and  is  now,  six  years  after  the 
operation,  in  good  health. 

CASE  12.  MELANCHOLIA. — The  follow- 
ing history  is  communicated  to  me  by  Dr. 
Humiston,  who  rescued  the  patient  after 
some  months  of  asylum  residence.  She 
was  seen  by  me  for  the  first  time  during 
her  convalescence.  The  patient,  a  woman 
thirty-five  years  old,  became  profoundly 
melancholy  after  the  birth  of  a  child. 
She  thought  her  own  soul  and  those  of  her 
immediate  family  lost  through  her  fault. 
The  onset  of  her  illness  was  quite  acute, 
with  a  severe  headache  forty-eight 
hours  after  the  birth  of  the  child, 
and  was  attended  with  intense  agita- 
tion and  sleeplessness.  She  had  no  pain, 
but  complained  that  her  head  felt  as  if 


28     Insomnia  and  Nerve  Strain 

it  had  been  split  open  and  her  soul  ex- 
tracted. 

The  uterus,  which  was  much  inflamed 
and  in  a  fibroid  condition,  was  curetted 
and  fixed  in  normal  position.  Between 
three  and  four  weeks  after  the  operation 
the  patient  was  discharged  from  the 
Hospital,  cured  physically,  and  much 
improved  mentally.  Although  more 
cheerful  she  still  suffered  from  delusions. 
Recovery,  however,  was  uninterrupted 
from  this  point,  and  the  patient  has 
remained  in  good  mental  health  and 
great  physical  vigor  for  twelve  years. 

CASE  13.  NEURASTHENIA. — The  asso- 
ciation of  neurasthenia  with  varied  dis- 
eases of  the  abdominal  and  pelvic  viscera 
is  significant.  Such  patients  as  the 
following  are  common  and  persistent 
apparitions  in  the  waiting-room.  The 
patient  was  a  woman  forty  years  of  age. 
She  was  fairly  well  until  the  birth  of  her 
first  child  some  years  ago.  After  that 
time  she  had  a  great  deal  of  trouble  with 
her  stomach,  had  to  be  careful  of  her 


Illustrative  Cases  29 

diet,  and  suffered  a  great  deal  from 
backache  and  headache.  For  three  or 
four  years  she  spent  most  of  the  time 
in  bed  and  was  much  weakened  and 
emaciated. 

Her  menstruation  was  regular  and  not 
especially  painful  but  it  was  attended 
with  considerable  prostration.  For  six 
or  eight  months  before  she  was  first  seen 
she  had  been  in  bed  continuously,  and 
was  eating  only  eggs,  broiled  beef-steak, 
and  dried  bread.  She  had  attacks  of  dis- 
tress in  the  stomach  and  a  distinct  draw- 
ing feeling  from  the  stomach  to  the  head. 
These  feelings  were  relieved  by  taking 
food,  which  she  did  quite  frequently.  The 
predominant  symptoms,  however,  were 
purely  nervous,  great  sensitiveness  to 
physical  and  psychic  shocks  and  prone- 
ness  to  fatigue,  giving  her  illness  the 
unmistakable  impress  of  the  fatigue  neu- 
rosis of  gastro-intestinal  type. 

The  patient  was  miserably  emaciated 
and  weak  but  not  anemic.  The  abdom- 
inal organs  appeared  normal,  the  tongue 
slightly  coated ;  the  pulse  eighty,  soft  and 


30     Insomnia  and  Nerve  Strain 

regular.  The  urine  contained  a  slight 
amount  of  albumin  but  no  sugar  and  no 
casts.  The  specific  gravity  was  1.026. 

Gastric  hyperacidity  was  diagnosed, 
and  marked  relief  followed  the  frequent 
giving  of  bicarbonate  of  soda  in  large 
amounts.  Radical  cure,  however,  was 
only  obtained  by  curetting  the  uterus  and 
removal  of  both  ovaries,  which  were 
badly  diseased.  This  was  successfully 
carried  out  by  Dr.  W.  H.  Humiston,  to 
whom  I  am  indebted  for  constant  co- 
operation in  this  and  other  similar  cases. 
Recovery  was  slow  and  the  management 
of  the  case  difficult.  The  patient  has 
now  been  in  good  health  for  more  than 
ten  years. 

CASE  14.  HYSTERIA  MINOR. — While 
hysteria  major  comprises  cases  present- 
ing certain  definite  and  severe  symptoms, 
hysteria  minor  is  a  vague  term  applied 
to  a  great  variety  of  conditions.  The  fol- 
lowing case,  communicated  to  me  by  a 
colleague, might  be  considered  hypomania, 
but  corresponds  more  nearly  with  the 


Illustrative  Cases  31 

conception  of  a  severe  but  not  major 
attack  of  hysteria.  The  patient,  a  young 
married  woman  twenty-five  years  of  age, 
rather  suddenly,  in  November,  1907, 
developed  fearful  pain  in  her  head  with 
attacks  of  hysterical  screaming.  She 
began  to  be  very  nervous  and  sleepless, 
cried  easily,  and  lost  weight  rapidly.  On 
the  3oth  of  December  an  impacted  lower 
third  molar  tooth  was  removed.  On  the 
1 7th  of  January,  1908,  she  was  better  in 
other  ways  but  the  screaming  attacks 
continued.  She  was  given  bromids  and 
frequent  nourishment.  Improvement 
began  on  this  regimen,  and  at  about  this 
time  pain  developed  in  an  upper  incisor 
tooth.  An  abscess  was  discovered  and 
the  tooth  removed.  The  screaming  at- 
tacks stopped  at  once  and  she  has  since 
been  perfectly  well. 

CASE  15.  MANIA. — The  excited  phase 
of  the  manic-depressive  group  is  well 
represented  by  the  following  fairly  typi- 
cal case  of  acute  mania.  The  patient 
was  a  physician,  twenty-eight  years  of 


32     Insomnia  and  Nerve  Strain 

age,  first  seen  a  week  after  the  maniacal 
condition  was  first  noticed.  He  had 
overworked  for  the  last  year  or  two  and 
for  a  time  had  been  sleepless,  but  it  was 
not  possible  to  ascertain  exactly  how  long. 
Otherwise  he  was  considered  well.  Dur- 
ing the  preceding  week,  however,  he  had 
acted  in  a  peculiar  way,  laughing  and 
talking  foolishly  but  insisting  that  there 
was  nothing  the  matter  with  him.  For 
some  weeks  he  had  complained  of  mod- 
erate pain  in  one  of  his  teeth.  When 
seen  he  was  rational  but  inconsistent  and 
foolish  in  his  talk  and  somewhat  inco- 
herent. By  skiagraph  the  right  upper 
first  bicuspid  tooth  was  found  badly 
impacted  and  was  drawn.  For  a  week 
or  ten  days  he  was  unmanageable,  but 
then  began  to  quiet  down,  slept  well,  and 
has  gone  on  to  a  progressive  recovery. 

CASE  16.  INCIPIENT  DEMENTIA  PRE- 
cox. — The  preceding  case  might  be  appre- 
hended as  one  of  beginning  mania  or  of 
dementia  precox.  The  two  conditions 
merge  into  each  other,  and  the  diagnosis 


Illustrative  Cases  33 

in  such  a  case  is  of  prognostic  but  not 
theoretical  importance.  The  following 
case,  however,  is  one  of  a  somewhat  differ- 
ent character.  Though  it  might  at  first 
sight  seem  mild,  its  manifestations  have 
the  importance  which  attaches  to  patients 
who  are  mentally  affected  but  hardly 
in  condition  to  be  sent  to  a  hospital. 

The  patient  is  a  bright  boy  of  sixteen, 
the  son  of  an  unusually  intelligent  pro- 
fessional man.  Until  a  year  before  he 
was  seen  he  was  well,  of  a  bright,  cheerful 
disposition,  and  a  general  favorite.  This 
was  with  the  exception,  however,  of  very 
moderate  nervousness  and  some  frontal 
headache  during  the  last  two  or  three 
years.  During  the  last  year  his  disposi- 
tion changed.  He  became  somewhat 
morose  and  irritable,  and  showed  less 
affection  for  his  family  and  friends  than 
before.  He  was  increasingly  nervous 
and  restless  so  that  he  could  not  sit  or 
read  long  and  only  had  four  or  five 
hours  of  sleep  during  the  night.  He  also 
had  practically  constant  frontal  head- 
ache and  a  severe  feeling  of  oppression 


34     Insomnia  and  Nerve  Strain 

in  the  occipital  region,  but  no  neuralgic 
or  dental  pains.  He  was  often  dizzy, 
especially  when  he  bent  his  head.  Being 
athletic  and  strongly  built  he  suffered 
from  a  good  many  kicks  and  blows  on  the 
head  in  playing  football.  The  right 
occipital  region  was  somewhat  sore  to 
pressure  and  on  pulling  the  hair. 

On  skiagraphic  examination  all  four 
of  the  molar  teeth  were  found  impacted. 
The  left  lower  third  molar  was  extracted 
first,  and  the  feeling  of  pressure  at  the 
back  of  the  neck  immediately  disappeared, 
and  from  that  time  on  sleep  was  some- 
what better.  The  upper  third  molar 
teeth  were  extracted  three  weeks  later, 
and  on  the  night  following  their  extrac- 
tion he  slept  soundly  for  ten  or  twelve 
hours.  After  this  he  slept  well  every 
night,  but  within  a  few  weeks  became 
restless  once  more  and  the  bad  feelings 
returned  to  his  head.  The  right  lower 
third  molar  tooth  was  then  extracted, 
and  the  head  pains  were  once  more 
relieved.  Sleep  has  continued  good,  the 
patient  has  gained  in  weight  steadily, 


Illustrative  Cases  35 

has  had  a  good  appetite,  felt  quiet, 
and  his  family  have  noticed  a  marked 
change  in  his  demeanor.  He  has  re- 
gained his  affectionate  bearing  toward 
them. 

In  writing  of  him  recently  his  father 
said:  "We  noticed  a  great  change  in 
John's  conduct  compared  with  that  pre- 
vious to  the  time  when  you  first  saw 
him.  This  became  more  noticeable  after 
the  last  extraction.  He  has  been  gentler, 
more  tractable,  affectionate,  regular  in 
his  habits,  and  more  natural  in  every 
way.  I  think  that  physically  he  has  been 
much  weaker  than  six  months  ago.  I 
suppose  the  nervous  shock  incident  to 
the  operations  may  account  for  that. 
Though  less  nervous  and  excitable,  he 
tires  with  the  least  exertion  and  requires 
a  great  amount  of  sleep.  His  appetite 
has  increased  every  day.  He  has  not 
had  any  desire  for  tea,  coffee,  or  hot 
drinks,  but  is  perfectly  satisfied  with 
cold  water." 

With  regard  to  the  weakness  noted  in 


36     Insomnia  and  Nerve  Strain 

this  case,  it  is  a  common  sequel  of  the 
removal  of  a  mechanical  stimulus.  The 
restless  expenditure  of  energy  is  replaced 
by  languor,  and  the  exhausted  ganglion 
cells  should  be  given  a  good  many 
months  of  repose  before  being  called  on 
for  much  exertion. 

CASE  1 7.  INCOMPLETE  DEMENTIA  PRE- 
cox. — The  importance  of  peripheral  irrita- 
tion in  the  members  of  the  community 
whomGrasset  calls  the  Semi-insane  and  the 
Semi-responsible,  suggested  in  the  above 
case,  is  also  of  interest  in  the  following 
recital  of  his  life-experience  given  to 
me  recently  by  a  friend  in  the  legal 
profession.  The  subject  of  this  little 
autobiographic  sketch  is  now  forty-three 
years  old.  He  says  he  was  always 
difficult  to  manage  at  school,  but  was  well, 
robust,  and  muscular.  When  he  was  a 
boy  he  had  a  controversy  with  a  teacher 
and  left  school  at  the  age  of  sixteen.  At 
that  time  he  struck  out  for  himself.  He 
then  suffered  for  ten  years  from  an 
uncontrollable  impulse  to  wander.  He 


Illustrative  Cases  37 

began  also  to  have  neuralgic  attacks, 
sometimes  on  one  side  of  the  face  and 
sometimes  on  the  other.  These  per- 
sisted for  ten  or  twelve  years  and  then 
ceased.  Pain  was  severe  in  the  third 
molar  region,  especially  in  the  lower 
jaw  on  the  right  side,  and  there  was  pain 
in  the  other  teeth,  both  upper  and  lower, 
and  pain  in  the  face.  Drugs  failed  to 
control  the  pain,  even  a  grain  of  morphin 
being  quite  useless.  The  left  lower  first 
molar  was  extracted  when  the  patient 
was  thirteen  years  old,  and  this  seems  to 
have  removed  the  pressure  from  that 
region  for  no  pain  was  felt  in  the  lower 
jaw  on  that  side.  Between  the  ages  of 
eighteen  and  twenty-five  he  had  occa- 
sional attacks  of  moderate  depression. 
The  patient's  wandering  was  all  over  the 
country,  mainly,  however,  in  the  west,  and 
was  usually  by  bicycle  or  train,  but  when 
he  was  out  of  money  he  beat  his  way  on 
freight  trains.  During  the  last  fifteen 
years  or  so  the  impulse  to  wander  has  not 
been  irresistible,  but  the  patient  travels 
when  it  is  convenient.  He  has  been 


38      Insomnia  and  Nerve  Strain 

able  to  study  his  profession  and  engage 
in  successful  practice. 


CASE  1 8.  DEMENTIA  PRECOX. — The 
next  case  is  one  of  typical  hebephrenia. 
The  patient  is  a  girl  nineteen  years  of  age 
who  was  never  very  strong  but  not 
especially  nervous.  In  February,  1907, 
she  began  to  be  low-spirited,  cried  fre- 
quently, and  was  afraid  that  she  would 
lose  her  mind.  Her  hands  and  feet 
began  to  be  cold,  and  she  was  especially 
depressed  and  weak  before  her  menstrua- 
tion. In  June  she  began  to  talk  of 
religious  matters,  prayed,  and  expounded 
the  Scriptures.  During  July  and  August 
she  talked,  sang,  and  played  on  the 
piano  incessantly,  was  excited  and  very 
contrary.  In  September  she  was  better, 
but  early  in  October  ran  out  into  the 
street  and  tried  to  escape.  Since  then 
she  has  torn  her  clothing  whenever  it 
was  possible,  has  bitten  and  scratched 
her  relatives,  and  been  resistant  and  often 
angry.  She  has  been  persistently  sleep- 
less throughout  her  illness.  She  has  had 


CASE  1 8. — Dementia  precox.  Impaction  of  a 
lateral  incisor  and  all  four  wisdom  teeth.  The  in- 
cisor and  one  lower  third  molar  are  shown  above. 


CASE     1 8.     Dementia 
Upper  third  molar. 


precox. 


CASE    22. — Mania, 
lower  third  mclar. 


Impacted 


Case  of  profound  melancholia, 
with  subconscious  sensory  reflex 
in  upper  incisor  teeth.  Impact- 
tion  of  upper  third  molar. 


Upper  fourth  molar  tooth. 


Illustrative  Cases  39 

no  pain  of  any  kind,  neuralgic  or  otherwise, 
and  has  often  said  that  she  wished  she 
had  pain.  During  the  latter  part  of  her 
illness  she  kept  her  hands  to  her  head  and 
neck,  a  part  of  the  time  moaning,  and 
trying  to  escape.  She  was  pale,  emaciated, 
and  had  the  drawn,  haggard  look  of  many 
such  cases.  There  have  been  cases  of 
insanity  in  the  family. 

When  seen  in  October  it  was  suggested 
that,  as  an  examination  of  the  pelvic 
organs  and  of  the  teeth  was  impossible 
without  an  anesthetic,  skiagraphs  be 
taken  under  ether,  a  vaginal  examination 
made,  and  any  necessary  operative  pro- 
cedures undertaken  at  once.  After  two 
months'  delay,  as  her  condition  remained 
unimproved,  this  was  done.  Skiagraphs 
developed  at  once  showed  impaction  of 
all  four  of  the  third  molar  teeth  and  of 
the  right  upper  lateral  incisor.  The 
pelvic  examination  showed  moderate 
retro  version,  but  no  pelvic  lesion  adequate 
to  account  for  the  symptoms.  The  sec- 
ond molar  teeth  in  the  lower  jaw  were 
extracted  to  allow  the  removal  of  the 


40     Insomnia  and  Nerve  Strain 

third  molars  impacted  against  them. 
The  third  molar  teeth  were  all  removed, 
as  were  the  right  lateral  incisor  and  one 
of  the  teeth  against  which  it  was  im- 
pacted, the  right  cuspid  tooth.  For 
some  days  after  the  operation  the  patient 
was  rather  more  restless.  Then  she 
became  quieter,  and  it  was  noted  that  she 
put  her  hands  to  her  neck  and  head  less 
often  than  before.  Her  hands  and  feet 
were  warm.  She  began  to  sleep  rather 
better.  From  this  time  on  she  gained  in 
weight  and  strength,  her  color  was  better, 
and  hypnotics  were  soon  discontinued. 
Of  late  screaming  fits  have  developed.  Al- 
though much  of  her  improvement  has 
persisted,  her  case  is  incomplete,  and  a 
year  will  probably  be  necessary  to  deter- 
mine the  result. 

DR.  O'BRIEN'S  CASES. — For  the  fol- 
lowing cases  I  am  indebted  to  Dr.  John 
D.  O'Brien  of  the  Massillon  State  Hos- 
pital. They  are  of  recent  observation 
and  are  selected  as  examples  of  what 
may  be  expected  among  the  more  imme- 


Illustrative  Cases  41 

diate  results  of  investigation  and  treat- 
ment of  dental  lesions,  the  first  of  the 
cases  having  been  examined  by  skiagraph 
in  October,  1907.  Dr.  O'Brien  has  many 
other  patients  at  present  under  observa- 
tion for  further  study. 

CASE  19.  MANIA. — The  first  patient 
is  a  robust  young  man,  eighteen  years  of 
age.  He  was  admitted  to  the  Hospital 
in  the  excited  phase  of  a  first  attack  of 
manic-depressive  insanity.  He  was  irri- 
table, destructive,  and  rather  profane. 
There  were  found  an  impacted  left  lower 
third  molar  tooth  and  an  abscess  with 
impact  ion  of  the  right  lower  third  molar. 
Extraction  of  the  affected  teeth  was  fol- 
lowed by  recovery  in  a  few  weeks  and  the 
patient  has  been  discharged. 

CASE  20.  MANIA. — The  second  patient 
was  also  in  a  first  attack  of  mania,  excit- 
able, pugilistic,  destructive,  filthy.  There 
were  found  an  impacted  left  lower  third 
molar  tooth  with  abscess  formation, 
and  also  a  large  abscess  at  the  base  of  a 


42     Insomnia  and  Nerve  Strain 

filling  in  another  tooth.  Extraction  has 
been  followed  by  amelioration  of  most 
of  the  mental  symptoms. 

CASE  21.  MANIA. — The  third  patient, 
twenty-five  years  old,  was  also  in  a  typi- 
cal maniacal  condition,  having  had  one 
such  attack  previously.  There  were 
found  an  impacted  third  molar  tooth,  an 
irregularity  and  projection  forward  of 
the  upper  incisor  teeth  with  great  dis- 
placement and  a  right  upper  second  molar 
tooth  impacted  at  right  angles.  Extrac- 
tion was  followed  by  marked  mental  and 
physical  improvement,  and  the  patient  is 
practically  ready  to  leave  the  Hospital. 

CASE  22.  HYPO  MANIA. — The  next  case 
was  one  of  a  first  attack  of  hypomania 
in  a  man  twenty-five  years  old.  A  left 
lower  third  molar  was  found  impacted. 
Recovery  followed  extraction  very 
promptly  and  the  patient  has  since  been 
discharged. 

CASE    23.     DEMENTIA    PRECOX. — The 


Illustrative  Cases  43 

fifth  case  was  one  of  dementia  precox  of 
the  katatonic  form,  in  a  young  man 
twenty  years  old.  There  were  found 
impaction  of  a  left  upper  third  molar 
tooth  and  impaction  of  a  right  upper 
third  molar  with  abscess  formation.  Re- 
covery followed  extraction. 

CASE  24.  MELANCHOLIA. — The  sixth 
case  was  one  of  depression  with  marked 
suicidal  tendencies  in  a  man  twenty-four 
years  of  age.  He  had  never  complained 
of  his  teeth.  Skiagraphic  examination 
showed  an  abscess  involving  the  second 
and  third  molars  of  the  upper  jaw  on  the 
right  side.  Extraction  was  followed 
by  recovery  and  the  patient  has  been 
discharged  from  the  Hospital. 

CASE  25 .  MELANCHOLIA. — The  seventh 
case  was  one  of  depression  with  marked 
emaciation  in  a  man  forty  years  of  age. 
In  this  case  there  had  been  a  pre- 
vious attack  of  hemiplegia.  Multiple  ab- 
scesses were  found  in  the  upper  j?w. 
Recovery  followed  extraction  of  the 


44     Insomnia  and  Nerve  Strain 

teeth  and  evacuation  of  many  pockets 
of  pus. 

SLEEP  AND  FATIGUE 

INSOMNIA. — Insomnia  is  a  symptom 
rather  than  a  disease,  and  although  it  is 
not  invariable  in  the  neuro-psychoses  it 
may  be  considered  as  practically  the 
recurring  link  which  binds  them  together. 
In  order  to  understand  the  phenomena  of 
insomnia,  it  is  necessary  to  make  at  least 
a  tentative  definition  of  sleep. 

Whatever  else  sleep  may  be,  it  must 
be  mainly  unconsciousness,  though  not 
alone  a  modification  of  cortical  function. 
This  is  attested  by  the  fact  that  the 
cortical  centres  of  memory  sometimes  con- 
tinue their  activity  during  sleep  and  that 
the  motor  and  even  the  perceptive  cen- 
tres are  active  in  somnambulism.  The 
negative  element  of  sleep,  rest  through 
inactivity,  is  possible  in  varying  intervals 
to  all  the  tissues  of  the  body.  The  active 
part  of  the  process  is  peculiar  to  the 
brain,  which  shares  the  inactivity  and 


Sleep  and  Fatigue  45 

adds  disjunction  of  the  higher  from 
the  lower  ganglionic  levels  in  degree 
varying  with  the  profoundness  of  the 
sleep.  Thus  comparative  rest  is  com- 
patible with  waking.  Considerable  activ- 
ity may  go  on  in  the  dormant  condition, 
but  this  activity  contains  a  relatively 
small  amount  of  interchange  between 
the  ganglionic  levels. 

The  subjective  element  of  insomnia  is 
necessarily  the  conscious  activity  of  the 
cortex.  The  natural  inference  is  that 
sleep  is  banished  because  the  cortical 
processes  of  perception  and  thought  go 
on.  An  objective  study,  however,  of 
cases  of  insomnia  shows  clearly  its  fre- 
quent dependence  on  the  activity  of  the 
lower  centres.  Comparison  of  the  cases 
just  cited  discloses  the  fact  that  proto- 
pathic  irritation  is  accompanied  by  insom- 
nia in  the  majority  of  instances.  If  the 
patient  makes  his  insomnia  an  object 
of  study  he  very  often  finds  that  wake- 
fulness  is  persistent  without  thought 
on  any  special  topic,  and  that  even 
when  waking,  the  thoughts  which  crowd 


46     Insomnia  and  Nerve  Strain 

on  his  mind  come  later,  gaining  power 
gradually  and  only  intensifying,  not 
causing  the  condition.  Even  in  so  uncer- 
tain a  science  as  medicine,  the  effect 
does  not  precede  the  cause. 

THE  FATIGUE  NEUROSIS. — Neuras- 
thenia in  the  wider  sense  is  too  indefinite 
a  concept  to  discuss  in  detail.  One  of  its 
prominent  symptoms,  however,  fatigue, 
is  common  to  many  cases  of  protopathic 
irritation  and  should  be  distinguished 
from  another  result  of  such  irritation, 
exhaustion. 

The  condition  of  a  ganglion  cell  which 
has  been  irritated  until  incapable  of 
further  functional  activity  is  one  of 
exhaustion.  This  point  may  be  reached 
either  with  or  without  fatigue  which  is 
a  protective  feeling  inhibitory  to  the 
action  of  the  cell.  The  normal  feeling  of 
fatigue  is  according  to  some  authorities 
due  to  poisons  which  accumulate  as 
waste  products.  As  a  result  of  muscular 
activity  they  are  in  and  about  the 
muscles,  affecting  the  sensory  elements. 


Sleep  and  Fatigue  47 

Fatigue  from  mental  activity  can  hardly 
be  considered  a  toxic  action  on  the 
ganglion  cell  itself  but  might  conceivably 
result  from  toxic  action  on  the  smaller 
cerebral  vessels. 

However  this  may  be,  it  is  important 
to  recognize  the  fact  that  fatigue  often 
occurs  practically  without  any  exertion 
whatever.  It  may  be  from  the  action  of 
extrinsic  toxins  carried  in  the  general 
blood -stream  and  is  one  of  the  common 
phenomena  of  purely  mechanical  proto- 
pathic  irritation.  Dental  caries  and 
impaction,  gastroptosis  and  the  torsion 
of  a  movable  kidney  are  frequent  causes 
of  the  heaviness  in  the  limbs  as  well  as 
the  thrills  and  wavy  feelings  so  typical 
of  the  neurasthenic  condition.  This 
symptom  may  occur  with  insomnia  or 
may  alternate  with  it  after  the  curious 
manner  of  rotation  of  protopathic  symp- 
toms in  general.  A  further  explana- 
tion of  fatigue  will  be  sought  later  in 
connection  with  other  phenomena  of 
action  and  reaction  in  the  nervous 
system. 


48      Insomnia  and  Nerve  Strain 

THE  EMOTIONS 

MANIC-DEPRESSIVE  INSANITY. — For- 
merly all  of  the  insanities  more  or  less 
emotional  in  expression  and  not 
otherwise  classified  were  included  in 
mania  and  melancholia.  The  conception 
of  the  psychoses  here  presented  is  that 
they  are  due  to  a  common  set  of  physical 
causes,  and  merges  all  neuroses  and 
psychoses  as  one  essential  process  with 
infinitely  varied  results,  like  the  har- 
monies and  discords  of  a  piano  with  one 
key-board  and  one  performer.  No  essen- 
tial difference  in  symptoms  exists  between 
the  different  psychoses,  as  they  blend  in 
infinite  variety.  Mania  and  melancholia 
are  only  somewhat  more  predominantly 
emotional  than  the  others  and  the  results 
of  study  of  the  emotions  in  these  disorders 
are  equally  applicable  to  other  members 
of  the  functional  group. 

Considering  then  melancholia  and 
mania  as  the  psychoses  predominantly 
emotional,  a  study  of  their  phenomena 
compared  with  the  emotions  which  con- 


The  Emotions  49 

stitute  so  large  a  part  of  normal  human 
activity  develops  the  fact  that  no  distinc- 
tion can  be  drawn  between  normal  and 
diseased  emotion,  that  is  emotion  exists 
in  absolutely  unbroken  series,  from  the 
lightest  reflexes  of  a  passing  word  or 
thought  to  the  most  profound  result  of 
the  extremest  physical  or  mental  shock. 

PHYSICAL  BASIS  OF  THE  EMOTIONS. — 
The  facts  pertaining  to  the  normal  emo- 
tions are  ably  presented  by  William 
James  in  his  Psychology.  According  to 
his  view  normal  emotion,  whether  from 
physical  or  psychic  causes,  is  always  due 
to  an  altered  visceral  condition.  A  sud- 
den noise  or  bright  light  or  the  sight  of  a 
revolver  is  the  direct  cause  of  the  wildly 
beating  heart,  pallid  face,  motor  unrest, 
and  dilated  pupils.  The  emotion  is  the 
cognition  of  these  visceral  changes.  Ap- 
prehension of  danger  is  not  necessary  to 
these  phenomena,  they  may  even  appre- 
ciably precede  the  conscious  sensation  of 
fear.  A  man  whose  legs  carry  him  off  a 
battlefield  finds  that  the  faster  he  runs 


50     Insomnia  and  Nerve  Strain 

the  more  frightened  be  becomes.  His 
motor  energy  and  wildly  beating  heart 
intensify  his  emotion. 

One  of  the  best  instances  of  what  may 
be  called  the  incubation  period  of  the 
emotions  is  seen  in  the  depression  follow- 
ing a  personal  misfortune.  Often  after 
such  an  event  there  is  for  a  time  mental 
exhilaration,  or  an  apparent  numbing 
of  sensibility  occurs  which  may  lead  the 
subject  to  think  that  he  is  callous  to  the 
loss  which  he  has  experienced.  There 
follow  lowered  heart  action,  a  heavy  feel- 
ing in  the  epigastrium,  heaviness  of  the 
arms  and  legs,  and  a  haggardness  about 
the  eyes  which  are  readily  apprehended 
as  grief,  and  which  in  persons  deficient 
in  physical  reactive  power  may  persist 
even  after  the  removal  of  the  exciting 
cause. 

MOODS. — The  emotions  in  lighter  grade 
called  moods  have  been  considered  by 
Head  in  connection  with  the  referred 
pains  which  he  has  studied  so  thoroughly. 
Such  moods  may,  however,  be  caused 


The  Emotions  51 

by  visceral  disease  without  referred  pain, 
notably  by  the  toxins  of  indigestion  and 
malassimilation.  A  fermenting  mass  of 
food  retained  in  the  stomach  may  cause 
a  simple  depression,  which  it  is  quite  im- 
possible to  shake  off  even  though  the 
cause  is  known,  but  which  is  promptly 
relieved  by  the  use  of  the  stomach-tube. 
Long-continued  melancholy  may  be 
caused  by  deficient  secretion  of  hydro- 
chloric acid  in  the  gastric  juice,  which 
is  relieved  by  the  administration  of  the 
acid. 

In  the  mildest  moods,  the  ordinary 
stronger  emotions  due  either  to  psychic 
impressions  or  disordered  viscera  and 
even  in  profound  melancholia  or  mania 
the  emotion  as  it  appears  in  consciousness 
is  the  result  of  visceral  change. 

DIRECTNESS  OF  EMOTIONAL  RESULT. — 
When,  as  is  usually  the  case,  the  emotions 
are  determined  not  by  environment  and 
circumstance,  but  are  the  result  of  a 
lesion,  the  ensuing  emotion  is  as  direct  a 
sequence  as  is  the  pain  of  a  burn  or  a  pin- 


52     Insomnia  and  Nerve  Strain 

prick.  This  is  none  the  less  true  because 
these  patients  in  thought  project  their 
emotions  into  causal  relation  with  their 
circumstances. 

PSYCHIC  PAIN. — The  difference  be- 
tween ordinary  pain  as  neuralgia,  and 
emotional  pain,  psychalgia,  is  not  great. 
Ordinary  pain  exists  in  consciousness  as 
a  percept  of  a  destructive  process  in  the 
periphery,  just  as  a  tactile  sensation  is 
a  percept  of  contact  in  the  periphery. 
Psychic  pain  is  a  percept  of  a  destructive 
or  calamitous  process  which  may  be 
located  more  or  less  dimly  in  the  body  as 
epigastric  distress,  a  feeling  of  constric- 
tion about  the  heart  or  other  organ,  or 
it  is  perceived  as  a  feeling  of  calamity 
without  spatial  relations,  projected  by 
intervention  of  the  intellect  into  the  ex- 
ternal world  of  environment  or  circum- 
stance. It  follows  from  Head's  later 
researches  on  sensation  that  true  visceral 
pain,  even  when  not  translated  into 
psychalgia,  is  sometimes  apprehended  as 
a  pain  or  burning  sensation  definitely 


The  Emotions  53 

located  outside  the  body,  and  this  is 
much  more  true  of  the  distinctly  emo- 
tional sequences  of  visceral  disease. 

CONTRAST  BETWEEN  NORMAL  AND  AB- 
NORMAL EMOTIONS. — There  is  no  store- 
house for  emotions  in  the  central  nervous 
system.  Memories  are  not  in  themselves 
emotional.  They  can  only  revive  emotion 
by  their  effect  on  the  viscera,  an  effect 
similar  to  that  of  the  original  psychic 
cause  with  ever  weakening  force  as  the 
memory  grows  dim.  The  continuing 
emotional  result  therefore  of  a  grief, 
sorrow,  or  fear  grows  less  apparent  with 
each  succeeding  day.  Memories  weaken 
as  present  impressions  grow  stronger,  and 
environment  powerfully  influences  nor- 
mal emotions. 

DEPTH  OP  EMOTIONAL  RESULT.  —In 
contrast  with  the  normal  emotions  are 
the  psychoses,  which  invariably  have  as 
their  enduring  basis  a  physical  disorder. 
The  patient  with  mania  is  taken  from 
the  scene  of  his  work  and  from  his  home, 


54     Insomnia  and  Nerve  Strain 

torn  from  those  he  loves,  imprisoned  in  a 
place  naturally  repugnant  to  him,  often 
with  food  and  surroundings  not  such 
as  those  to  which  he  is  accustomed.  His 
emotional  state,  however,  what  the  Ger- 
mans more  compactly  term  the  Stimmung, 
is  determined  by  his  sickness,  and  for- 
tunately for  him  it  is  joy.  The  melan- 
cholic is  more  often  kept  at  home, 
surrounded  by  his  loved  ones,  often 
given  the  delights  of  travel,  soothed  by 
music,  and  diverted  in  every  way,  but 
his  emotion  is  determined  by  his  illness. 
It  is  sadness  so  profound  that  these 
patients  cut  their  own  arteries,  bite  and 
swallow  fragments  from  drinking-vessels, 
hack  at  their  throats  with  jagged  glass. 
No  torment  is  for  them  too  hideous  to 
lend  a  terror  to  the  approach  of  death. 

It  may  be  said  in  general  that  an 
emotional  deviation  from  the  normal 
which  persists  from  day  to  day  in  the 
absence  of  an  enduring  psychic  cause 
is  invariably  physical  and  the  cause 
should  be  looked  for  in  the  viscera. 
The  apparent  persisting  cause  may  be 


The  Emotions  55 

a  memory  either  fabricated  or  true,  but 
when  memory  does  not  weaken  its 
endurance  is  the  result,  not  the  cause, 
of  the  emotional  state. 

Melancholia  should  not  be  apprehended 
as  ganglionic  sedation.  It  is  the  reverse 
of  this,  an  agony  so  extreme  as  to  be 
paralleled  by  no  physical  pain  except 
possibly  the  most  violent  renal  colic  or 
gastralgia.  The  theory  that  mania  and 
melancholia  are  identical  but  that  mania 
represents  a  deeper  grade  of  reduction 
is  hardly  tenable.  The  word  reduction 
is  misleading;  the  process  in  both  in- 
stances is  primarily  an  excitation,  and 
mania  in  its  milder  forms  is  a  trivial 
derangement  compared  with  the  pro- 
fundity of  the  severer  melancholias. 

MUTABILITY  OF  THE  EMOTIONS. — Al- 
though elation  and  depression  are  so  dif- 
ferent as  to  seem  opposed,  they  do  not 
neutralize  each  other  like  an  acid  and 
an  alkali  but  mingle  in  consciousness 
like  bitter  and  sweet ;  in  other  words  we 
are  dealing  with  a  vital  and  not  a  chemi- 


56     Insomnia  and  Nerve  Strain 

cal  phenomenon.  In  the  easily  excita- 
ble whether  children  or  adults  laughter 
changes  to  tears  with  proverbial  quick- 
ness, and  a  sudden  stimulus  may  provoke 
an  emotion  which  may  be  termed  pure 
excitement  without  being  felt  with  defi- 
niteness  as  either  sorrow  or  joy. 

When  manic-depressive  insanity  occurs 
as  the  result  of  a  tremendous  event 
whether  of  joy  or  of  sorrow,  the  psychosis 
takes  color  from  the  enduring  antecedent 
emotional  state,  so  that  a  sudden  great 
joy  is  likely  to  be  followed  by  a  burst  of 
tears  and  consequent  melancholia.  Dis- 
aster is  in  many  instances  followed  by 
elation  and  mania. 

So  far  as  emotion  affects  purely  mental 
activity,  it  may  be  considered  as  a  force 
pulling  on  the  intellectual  content. 
Two  such  forces  acting  on  the  mind  never 
pull  away  from  each  other  but  in  lines 
that  diverge  at  an  angle.  Here  the  anal- 
ogy with  non- vital  energy  ceases.  The 
effect  on  mental  inertia  is  to  move 
thought  and  perception  not  on  a  line 
lying  between  the  other  two  but  to  some 


Subconscious  Sensory  Reflexes  57 

extent  along  each;  in  other  words,  and 
with  another  analogy,  emotion  is  not  a 
crucible  for  the  fusion  of  thought  but 
stimulates  it  to  movement  in  many 
simultaneous  ways. 

SUBCONSCIOUS  SENSORY 
REFLEXES 

SENSORY  MANIFESTATIONS  IN  THE 
PSYCHOSES. — In  considering  pain  it  is 
possible  to  divide  positive  phenomena  of 
that  nature  into  extrinsic  pains  set  up 
by  an  obvious  external  cause,  and  intrin- 
sic ones,  which  arising  in  the  body  itself 
are  sometimes  in  the  locality  of  the  cause, 
but  are  often  due  to  a  disorder  so  obscure 
or  distant  as  to  leave  a  doubt  of  the  loca- 
tion and  kind,  even  at  times  of  the  reality 
of  the  noxious  agent.  While  the  skin 
is  the  usual  organ  of  perception  of  exter- 
nal objects  and  extrinsic  pains  the  viscera 
have  long  been  considered  the  main  cause 
of  intrinsic  pains  and  their  exploration 
in  this  relation  is  one  of  the  ordinary 
subjects  of  medical  research. 


58      Insomnia  and  Nerve  Strain 

The  results  in  consciousness  of  proto- 
pathic  excitation  are  not  only  pains, 
but  also  intense  but  vague  feelings  of  dis- 
comfort, waves,  thrills,  and  tense  feelings 
in  viscera,  body,  or  extremities.  The 
greater  and  more  important  part,  how- 
ever, of  this  process  is  subconscious, 
visceral  function  and  mentality  being 
alike  more  powerfully  affected  by  the 
assaults  of  protopathic  nerve  waves  be- 
low the  level  of  consciousness,  in  a  way 
comparable  to  the  greater  actinic  power 
of  waves  beyond  the  violet  end  of  the 
spectrum. 

Excitants  of  the  protopathic  system 
may,  however,  affect  epicritic  nervous 
structures  at  the  same  time  with  distinct 
localizing  pains  as  a  result. 

Protopathic  irritation  as  it  increases  in 
intensity  does  not  always  cause  greater 
pain.  As  a  concrete  example,  dementia 
precox  caused  by  dental  impaction  has 
almost  the  clearness  of  a  laboratory 
experiment,  as  in  it  the  severest  symp- 
toms are  set  up  by  the  simplest  irri- 
tant. Pains  may  be  from  beginning  to 


Subconscious  Sensory  Reflexes  59 

end  quite  lacking.  Even  the  dull  ache 
of  protopathic  irritation  may  be  absent 
in  the  limbs,  and  salient  features,  such 
results  of  subconscious  nerve-storms  as 
the  overpowering  desire  to  escape,  tear- 
ing out  of  hair,  rocking  to  and  fro,  and 
continual  moaning,  are  the  symptoms 
attracting  attention.  When  questioned 
these  patients  often  deny  any  pain  or 
discomfort  whatever.  Such  actions,  how- 
ever, often  follow  the  lines  of  referred 
pains  and  are  not  only  significant  of 
irritation  but  have  a  distinct  localizing 
value. 

In  discussing  the  mode  of  action  of  the 
sensory  system  it  is  necessary  as  far  as 
possible  to  consider  pain  as  a  valuable 
but  rare  indication;  other  sensory  phe- 
nomena are  obscure  but  common.  The 
protopathic  system  as  it  exists  in  the 
more  primitive  forms  of  animal  life  is 
direct  in  its  reactions.  Motion  follows 
directly  on  the  stimulus.  Epicritic  func- 
tion and  thought  do  not  supplant  but 
are  superimposed  on  the  earlier  forms  of 
reflex  and  automatic  reaction.  They 


60     Insomnia  and  Nerve  Strain 

are  switched  in  on  the  lower  systems 
as  a  distinct  afterthought  and  a  protec- 
tive mechanism  which  in  man  only  par- 
tially replaces  the  lower  ones. 

Consciousness  is  in  full  relation  with 
epicritic  sensibility.  We  are  adapted 
to  know  the  outside  world  clearly,  and 
ourselves  as  fountains  of  vague  emotion 
and  organs  dimly  perceived.  The  parts 
of  our  body  clearly  apprehended  are  not, 
our  inner  selves  but  our  outer  lines  of 
communication  with  the  environment. 
The  organ  of  knowing  is  a  thing  apart. 
It  is  a  protective  mechanism  of  wider 
range,  but  more  a  matter  of  cognition 
and  less  of  vitality. 

REFERENCE  OF  SUBCONSCIOUS  PAINS. — 
The  dominant  ego  is  usually  a  mani- 
festation of  subconscious  nerve  force. 
Some  of  the  most  marked  and  typical 
examples  of  such  subconscious  domina- 
tion are  found  in  dementia  precox. 

When  irritation  at  the  periphery  causes 
a  continuous  current  of  nerve-waste  from 
the  basal  ganglia  lines  of  least  resistance 


Subconscious  Sensory  Reflexes  61 

are  occasionally  set  up  from  some  ad- 
jacent sensory  region,  and  the  resulting 
discharge  from  that  group  of  cells  is 
apprehended  as  a  pain,  a  feeling  of  op- 
pression, or  a  vague  distress.  As  neural- 
gia, headache,  pressure  at  the  nape  of 
the  neck,  and  other  like  sensory  mani- 
festations they  are  frequent  in  the  psy- 
choses, especially  in  melancholia  and 
dementia  precox.  When  intense  they 
may  be  withdrawn  from  consciousness. 
Protective  movements  persist,  however, 
as  reflex  or  automatic  actions  of  the 
kind  previously  mentioned.  This  oc- 
curred as  a  typical  instance  in  Case  17 
of  the  present  series. 

One  patient  seen  recently  was  pro- 
foundly melancholy  for  six  or  eight 
years,  suicidal,  and  for  the  greater  part 
of  the  time  speechless.  By  continual 
effort  the  patient  had  pushed  the  upper 
front  teeth  backward  at  an  angle  of 
about  forty-five  degrees  from  the  vertical. 
In  this  patient  both  upper  and  lower 
third  molars  were  impacted  on  the  left 
side. 


62      Insomnia  and  Nerve  Strain 

In  another  patient  the  subject  of 
violent  attacks  of  homicidal  melancholia 
for  the  last  twenty-five  years  and  now 
for  two  years  confined  in  one  of  the 
State  Hospitals,  the  upper  front  teeth 
have  been  continually  picked  at  with  a 
pin  through  their  whole  length  to  the 
ends  of  the  roots  and  so  persistently 
that  holes  have  been  picked  quite  through 
them.  The  left  second  molar  tooth  has 
been  picked  out  until  it  is  nothing 
but  a  shell.  Impacted  against  this 
second  molar  tooth  was  a  third  molar, 
and  no  other  molar  teeth  have  been 
picked  out  except  the  one  against  which 
the  impaction  has  taken  place.  When 
pain  occurs  as  the  result  of  the  impaction 
of  upper  third  molar  teeth  it  is  often  in 
the  adjacent  second  molars  and  runs 
forward  along  the  jaw  occurring  in  the 
front  teeth.  This  patient  denied  pain 
in  the  teeth  but  picked  at  them  with  a 
dreamy  faraway  look  as  if  the  process 
gave  her  relief. 

In  a  case  of  violent  hebephrenia  of  six 


Atavistic  Symptoms  63 

or  seven  years'  standing  with  the  patient 
already  somewhat  demented,  there  has 
been  in  addition  to  beating  the  head 
against  the  wall  and  thrusting  pins  into 
the  flesh  a  tearing  out  of  the  hair  all  over 
the  head,  especially  over  the  left  parietal 
region.  This  patient  had  an  impaction 
of  the  left  upper  third  molar  tooth. 

The  occurrence  of  these  subconscious 
sensory  reflexes  is  most  significant. 
Such  acts  furnish  the  dramatic  element 
of  insanity  in  the  ordinary  idea  of  the 
madhouse,  although  they  may  be  quite 
lacking  in  cases  of  profound  irritation. 
When  present  they  have  a  distinct 
localizing  value. 

ATAVISTIC  SYMPTOMS 

PROTECTIVE  FLIGHT. — When  a  cater- 
pillar is  touched  it  doesn't  stop  to  look 
at  the  threatening  hand  but  crawls  away 
with  tumultuous  steps  as  if  each  segment 
were  imbued  with  an  especial  and  distinct 
desire  to  escape.  In  dementia  precox 


64     Insomnia  and  Nerve  Strain 

the  impulse  to  wander  is  an  analogous 
phenomenon,  not  the  presentation  of  a 
desire  in  thought  but  the  vague  compul- 
sion of  a  feeling  coming  from  an  irritated 
periphery,  a  feeling  of  unrest  that  per- 
vades the  emotional  field  and  in  its  sever- 
est form  abstracts  the  mind  from  normal 
sentiment  and  intellectual  activity. 

CATALEPSY. — Among  the  most  striking 
symptoms  of  the  psychoses,  especially  in 
severe  cases  of  melancholia  and  demen- 
tia precox,  are  motor  phenomena  known 
as  catalepsy  and  waxy  rigidity.  These 
rigid  conditions  are  in  no  sense  voluntary. 
Patients  have  been  known  to  remain  in 
the  same  position  in  a  state  of  muscular 
tension  for  two  or  three  years  without 
themselves  making  any  change.  Such 
a  feat  is  quite  beyond  the  power  of  voli- 
tion, and  it  may  be  doubted  whether  the 
cortical  centres  are  capable  of  such  pro- 
longed effort  even  under  the  domination 
of  the  most  powerful  stimuli. 

Protective  rigidities  of  this  kind  are 
found  in  abundance  among  the  lower 


Atavistic  Symptoms  65 

animals.  Many  insects  seek  to  escape 
notice  by  rigid  simulation  of  twigs  and 
other  inanimate  structures.  The  truly 
cataleptic  rigidity  of  the  ordinary 
walking-stick  and  mobile  rigidity  of  the 
praying  mantis  are  evoked  by  protopathic 
stimulation.  Some  higher  animals  such 
as  hares  and  deer  are  quiet  so  long  as 
they  think  that  they  are  unseen,  and 
when  it  is  obvious  that  they  are  discov- 
ered seek  escape  by  protective  flight. 

The  two  most  powerful  emotions  that 
come  to  the  lower  animals  are  the  earliest 
prototype  of  fear  and  the  desire  for  food. 
The  reactions  of  the  protopathic  system 
to  fear  are  seen  in  the  rigidity  as  well  as 
in  the  protective  flight  of  the  frightened 
hare,  ferocity  in  the  mobile  rigidity  of 
the  mantis  and  the  rush  of  the  leopard. 
Physical  manifestations  of  such  emotions 
are  present  in  the  psychoses  even  when 
the  emotions  themselves  are  absent. 

FUGUES. — The  longer  and  more  fully 
developed  examples  of  protective  flight 
are  called  fugues.  They  are  essentially 


66     Insomnia  and  Nerve  Strain 

irritative  in  origin  and  are  especially  apt 
to  be  evoked  as  are  reflex  pains  by  atmos- 
pheric conditions.  They  occur  also  in 
the  lower  animals,  horses  and  cattle  some- 
times being  known  to  drift  for  hundreds 
of  miles  before  an  oncoming  storm. 

Protective  flight,  fugues,  and  rigidity 
then  as  they  occur  in  the  psychoses  may 
be  considered  as  analogues  of  the  same 
phenomena  in  the  lower  animals,  and, 
as  direct  products  of  the  protopathic 
system,  should  be  differentiated  from  the 
motor  results  of  delusions  and  other 
mental  processes. 

DERANGEMENTS  OF  FORMAL 
THOUGHT 

DELUSIONS. — Of  the  symptoms  of  the 
psychoses,  delusions  are  the  most  fortuit- 
ous. Their  trend  and  existence  depend 
more  on  the  acquired  than  on  the 
original  portion  of  the  apparatus  of 
mentality,  and  in  the  milder  cases  they 
are  in  much  greater  degree  subject  to 
circumstance  and  environment  than  are 


Derangements  of  Formal  Thought  67 

the  physical  symptoms.  The  study  of 
lycanthropy,  folie  a  deux  and  in  fact  of 
almost  any  individual  case  shows  that 
delusions  like  normal  ideas  are  simply 
the  attempts  of  the  mind  at  interpreta- 
tion of  the  perceptual  material  at  hand- 
Ideas  in  the  insane  as  in  the  sane  take 
color  continually  from  the  inflowing  per- 
ceptual currents,  percepts  of  nerves  of 
special  sense  blending  with  the  mental 
content  and  being  informed  and  colored 
by  percept,  sensation,  and  emotion  from 
the  viscera.  Delusions  are  thus  elabora- 
tions and  effects  of  the  lesion  by 
indirection,  not  vital  and  scarcely  integral 
parts  of  the  disease-picture.  In  fact  the 
solution  of  most  of  the  problems  pre- 
sented by  the  psychoses  lies  in  the  study 
of  the  lower-level  phenomena  where 
brain  and  sympathetic  system  meet,  and 
where  it  is  doubtful  whether  one  has 
to  deal  with  mind  at  all  as  present  in 
consciousness. 

IDEATED  SENSATIONS. — Many  delusions 
may  be  considered  as  ideated  sensations  of 


68      Insomnia  and  Nerve  Strain 

touch,  a  phrase  and  idea  borrowed  from 
that  most  suggestive  of  art-critics  Bern- 
hard  Berenson.  In  his  recent  book 
North  Italian  Painters  of  the  Renaissance 
he  gives  a  re*sum6  of  his  earlier  views  on 
the  sensory  implications  of  Giotto's  paint- 
ings important  to  the  student  of  psychic 
values  in  relation  to  percepts  of  special 
sense  as  translated  into  terms  of  mind 
and  emotion. 

ORIGIN  OF  DELUSIONS. — The  mode  of 
genesis  of  delusions  in  the  psychoses  will 
be  apparent  on  consideration  of  proto- 
pathic  influence  on  thought  in  general. 

Thought  is  normally  subject  to  volition 
as  are  speech  and  movements  of  the 
limbs,  but  is  more  mobile  and  elusive. 
At  times  with  an  inertia  requiring  much 
effort  to  overcome,  sometimes,  as  for 
instance  in  insomnia,  its  near  congener, 
mania,  and  many  other  conditions,  it 
has  compelling  power  practically  irresist- 
ible. This  is  the  case  during  protopathic 
stimulation,  produced  either  physically 
or  by  means  of  ideated  sensations.  The 


Derangements  of  Formal  Thought  69 

result  is  thus  identical  whether  from 
an  impacted  tooth,  the  ingestion  of 
alcohol  or  what  is  called  a  stimulating 
environment,  music,  brilliant  conversa- 
tion or  other  like  factor  of  emotion.  Pro- 
topathic  excitation,  however,  is  capable 
when  transmitted  into  other  channels, 
of  drawing  attention  and  consciousness 
away  from  ordinary  thought,  impulsion 
being  to  certain  limited  fields,  as  for 
instance  depressive  memories.  In  an 
overwhelming  tide  of  subconscious  activ- 
ity higher  mentality  may  be  submerged. 
This  latter  condition  is  one  of  pseudo- 
dementia. 

Under  protopathic  stimulation  senti- 
ment and  fancy  are  often  quickened  and 
thought  finds  readier  expression  than 
is  usual.  The  effect  on  mentality  may 
be  desirable  throughout  the  whole  range 
of  feeling.  Whether  formal  thought  is 
often  thus  stimulated  is  doubtful.  That 
it  may  be  much  impaired  even  in  the 
early  stages  of  stimulation  is  certain. 
These  circumstances  of  emotional  and 
sensory  domination  over  and  weakening 


70     Insomnia  and  Nerve  Strain 

of  formal  thought  are  favorable  to  the 
growth  of  delusions  which  are  common 
phenomena  in  the  sane,  and  in  protopathic 
insanity  are  not  neomorphic  but  attempts 
at  interpretation  of  endogenous  feelings 
and  emotions. 

Thought  then  may  be  stimulated, 
weakened,  or  perverted  by  protopathic 
stimulation.  Diversity  of  result  in  this 
domain  as  in  those  of  sensation,  motion, 
and  emotion  is  not  from  inherent  differ- 
ence between  the  pathologic  processes 
but  is  due  to  selective  transmission  of 
the  resulting  nervous  discharge  through 
various  paths  of  least  resistance. 

INDUCTIVE  INHIBITION 

ANESTHESIA. — We  are  now  ready  to 
discuss  the  numbing  of  ordinary  sensi- 
bility amounting  to  practical  anesthesia 
which  is  so  striking  a  feature  of  the 
worst  cases  alike  of  mania,  melancholia, 
and  dementia  precox. 

We  may  observe  as  a  preliminary 
consideration  that  although  epicritic  sen- 


Inductive  Inhibition  71 

sation  in  the  skin  overbalances  proto- 
pathic  and  is  normally  more  vividly 
present  in  consciousness  the  protopathic 
system  predominates  throughout  the 
body  as  a  whole  in  size  and  vigor  of 
action  as  well  as  in  importance. 

The  infant  is  born  practically  devoid 
of  epicritic  function  but  soon  attains  to 
a  fair  amount  of  localizing  information 
gained  from  all  of  the  epicritic  terminals. 
Protopathic  information  on  the  other 
hand  remains  incomplete  throughout  life, 
but  may  be  added  to  from  time  to  time. 
There  is  more  individual  variation  in 
protopathic  than  in  epicritic  sensibility 
with  regard  to  completeness,  special 
viscera  giving  reactions  of  pain  in  some 
individuals  and  none  at  all  in  others. 

The  phenomenon  observed  by  Head  of 
excessive  pain  produced  by  stimulating 
skin  supplied  by  protopathic  but  not  by 
epicritic  fibres  may  be  explained  by 
supposing  that  currents  in  the  nerve- 
fibres  are  governed  by  the  same  laws 
with  electric  currents  under  the  same 
circumstances. 


72     Insomnia  and  Nerve  Strain 

Such  currents  when  passing  in  insulated 
wires  generate  in  wires  running  parallel 
to  them  a  current  in  the  opposite  direction 
on  each  closure  of  the  circuit  and  a 
weaker  current  in  the  same  direction  on 
the  opening  of  the  circuit,  so  that  the 
effect  of  an  interrupted  current  is  the 
increase  of  electric  activity  in  the  opposite 
direction  in  wires  parallel  to  it.  Nerve- 
force  is  supposed  to  flow  in  all  three 
sensory  systems  in  the  same  direction, 
that  is  centripetally ;  if  so  the  effect  of 
the  action  of  any  one  system  is  to  dimin- 
ish the  activity  of  each  of  the  others. 
Thus  each  system  is  in  a  way  regulated 
by  the  others. 

CONVULSIVE  SEIZURES  AND 
CHOREIC  SPASM 

MECHANISM  OF  SENSATION. — To  un- 
derstand even  approximately  the  relation 
of  structure  with  function  in  the  nervous 
system  a  comparison  is  necessary,  and 
only  one  is  in  any  degree  adequate,  the 
time-honored  one  of  an  electric  apparatus. 


Convulsive  Seizures  73 

Let  us  suppose  then  a  battery  of  cells 
in  the  central  ganglia  and  sensory  nerve- 
fibres  as  wires  coming  in  from  the 
periphery.  These  countless  distal  signal- 
stations  must  be  provided  each  with  a 
rheostat  to  account  for  the  curious 
phenomena  of  irritation.  Every  one  famil- 
iar with  the  water  rheostat  will  realize 
that  the  carbon  plates  which  when 
approximated  allow  the  current  to  pass 
may  easily  be  duplicates  of  the  sensory 
end-bulbs;  this  is  an  explanation  of 
the  gradually  increasing  discharge  in  the 
basal  ganglion  cells  determined  by  rising 
peripheral  irritation.  In  fact  the  very 
circumstances  and  means  of  irritation 
are  such  as  to  suggest  a  similar  or 
identical  action.  As  an  example  a  mod- 
erate poison  swells  the  terminals  or 
otherwise  bridges  the  gap  and  allows 
the  current  to  pass;  or  a  severe  toxin 
or  heat  which  besides  the  swelling  causes 
corrosion  and  thus  closure  of  the  circuit; 
or  worst  of  all  simple  mechanical 
pressure,  which  as  it  persists  and 
increases  day  by  day  never  breaks  but 


74     Insomnia  and  Nerve  Strain 

pushes  the  plates  relentlessly  together 
until  the  battery  is  fairly  short-circuited ; 
thus  from  renal  torsion  or  dental  impac- 
tion  comes  the  terrible  outpouring  of 
energy  in  this  or  the  other  part  of  the 
ganglionic  network  as  emotion,  motion, 
or  sensation,  and  then  exhaustion  which 
persists  until  pressure  is  relieved  or 
death  ensues. 

A  ganglion  cell  like  a  galvanic  cell  is 
active  in  inverse  proportion  to  the  resist- 
ance in  the  circuit,  and  the  current  set 
up  by  partial  or  complete  closure  at  the 
periphery  selects  in  passing  in  and  from 
the  ganglia  lines  of  least  resistance  in 
both  fibre  and  cell. 

The  theory  of  the  neuron  as  a  working 
hypothesis  is  here  adopted,  together  with 
the  generally  received  notions  of  the 
cortex  as  the  principal  seat  of  conscious- 
ness, and  the  basal  ganglia,  here  used  to 
include  the  spinal  cord,  as  the  location 
of  reflex  and  subconscious  motor  and 
sensory  nervous  activity. 

LOCATION  OF  CONSCIOUSNESS. — In  or- 


Convulsive  Seizures  75 

der  to  an  understanding  of  the  reactions 
of  the  central  and  peripheral  nervous 
mechanism  to  mechanical  and  toxic  stim- 
uli a  brief  consideration  will  be  necessary 
of  consciousness  in  its  relation  to  the 
ganglionic  masses,  and  of  the  familiar 
sensory  and  motor  reactions  to  organic 
disease  of  the  brain  as  well  as  to  toxic 
agents. 

It  is  generally  agreed  that  conscious- 
ness is  not  a  function  supplied  by  a 
cerebral  centre  but  is  an  attribute  of  the 
whole  cortex,  varying  in  intensity  at 
different  times  and  in  different  individuals 
and  subject  to  a  limited  high-tension 
phenomenon  variable  through  the  whole 
field  of  consciousness,  to  some  extent 
subject  to  volition,  called  attention. 
While  attention  is  variable  the  com- 
paratively mild  and  diffuse  phenomena 
of  consciousness  go  on  so  far  as  is  known 
from  birth  to  death,  conditioned  only 
on  an  activity  of  the  cells  in  which  they 
reside.  When  the  activity  of  any  of  these 
cells  is  increased  by  stimuli  from  without 
or  from  other  parts  of  the  brain,  con- 


76     Insomnia  and  Nerve  Strain 

sciousness  becomes  more  intense,  until 
a  point  is  reached  where  attention  is 
involuntary  and  compulsive. 

THE  CORTEX  NEVER  DIRECTLY  STIMU- 
LATED.— Consciousness  being  thus  directly 
variable  with  the  activity  of  the  cells  we 
may  inquire  whether  their  phenomena 
may  be  produced  by  direct  irritation. 
The  fundamental  proposition  may  be 
laid  down  that  all  stimulant  action  in  the 
nervous  system  whether  by  mechanical 
agents,  toxins,  or  organic  disease  is  exerted 
on  the  basal  ganglionic  masses  or  per- 
ipheral nerve  structures,  never  on  the 
cortical  centres.  As  applied  to  the 
neuro-psychoses  it  must  at  present  suffice 
to  examine  the  phenomena  of  epilepsy 
and  chorea,  in  order  to  compare  them 
in  mode  and  place  of  origin  with  the 
psychoses  under  discussion. 

The  evidence  is  conclusive  that  the 
cortex  may  be  experimentally  cut,  lacer- 
ated, and  subjected  to  chemical  irritation 
to  any  extent  without  being  stimulated 


Convulsive  Seizures  77 

to  activity  of  either  its  motor  o,r  sensory 
functions  or  to  consciousness.  This  is 
also  abundantly  evident  at  operations  on 
the  cortex,  the  electric  current  being  the 
only  apparent  stimulant,  though  irritants 
are  many. 

EPILEPTIFORM  CONVULSIONS.  —  The 
phenomena  of  the  irritant  action  of  brain 
tumors  and  other  lesions  are  more  com- 
plex. As  a  result  of  cortical  disease 
convulsions  are  set  up,  sometimes  of  the 
common  epileptic  type,  sometimes  begin- 
ning in  one  group  of  muscles  and  spreading 
to  others  until  they  become  general.  A 
sensory  aura  is  held  to  indicate  an 
involvement  of  the  sensory  centres,  the 
discharge  beginning  in  the  sensory  cortex 
and  spreading  to  the  motor  area. 

That  the  centres  of  conscious  sensory 
activity  in  the  cortex  are  stirred  to 
exaggerated  action  one  after  the  other 
with  the  patient  in  profound  unconscious- 
ness is  as  near  as  possible  to  the  unthink- 
able. There  is  here  no  question  of 
exhaustion  from  over-stimulation,  uncon- 


78     Insomnia  and  Nerve  Strain 

sciousness  usually  dates  from  the  begin- 
ning of  the  attack  and  the  centres 
resume  their  function  a  few  moments 
after  its  cessation. 

No  SENSORY  OR  PSYCHIC  EPILEPSY. — 
It  is  further  true  that  there  is  neither 
sensory  nor  psychic  epileptic  spasm 
corresponding  to  the  motor  convulsion. 
Such  a  paroxysm  may  be  easily  imagined. 
It  would  necessarily  be  terrible  pain  either 
involving  successively  one  part  after 
another  of  the  sensory  field,  in  fact  a 
sensory  Jacksonian  spasm,  or  like  a 
general  convulsion,  a  sudden  universal 
outburst.  Instead  of  such  a  storm  there 
is  a  light  breeze,  an  aura,  consisting  of 
a  tingling  feeling,  a  flash  before  the  eyes  or 
other  short-lived  phenomenon  ushering 
in  a  motor  attack. 

So-called  psychic  equivalents  are  in 
no  sense  epileptic  outbursts  of  mentality. 
So  far  from  being  increments  of  intellec- 
tual energy  they  are  characterized  by 
diminution  of  consciousness  much  like 
that  of  ordinary  sleep,  as  is  indicated 


Convulsive  Seizures  79 

in  their  usual  name,  dream-states.  In 
other  words  they  are  memories  not 
evoked  by  the  disease  but  modified  by 
a  partial  withdrawal  of  consciousness. 

The  same  reasoning  has  even  more 
significance  when  applied  to  the  centres 
for  the  storage  of  visual,  auditory,  and 
other  memories.  In  the  adult,  memories 
are  innumerable  as  the  sea-sands,  and 
their  revival  is  only  conceivable  as  occur- 
ring in  consciousness  and  varying  with 
consciousness.  If  a  discharge  were  to 
sweep  through  this  preponderating  por- 
tion of  the  cortical  gray,  gathering  force 
as  it  passed  from  ganglion  to  ganglion 
the  resultant  nerve-storm  with  its  accom- 
panying agony  of  heightened  conscious- 
ness would  compare  with  no  convulsion 
of  insentient  nature  but  the  awful 
majesty  of  the  tornado.  There  is  for- 
tunately in  human  experience  no  such 
event  as  this.  The  brief  sensory  phenom- 
ena that  usher  in  an  attack  are  only 
such  signals  as  may  be  sent  in  a  moment 
and  then  the  wires  are  down  in  the  storm. 


8o     Insomnia  and  Nerve  Strain 

MOTOR  CONVULSIONS  NEVER  CORTICAL. 
— The  consideration  of  motor  phenomena 
in  epilepsy  is  equally  conclusive.  Even 
a  superficial  comparison  of  the  epileptic 
movements  with  action  caused  by  normal 
discharge  in  the  motor  area  of  the  cortex, 
shows  the  widest  possible  difference  in 
quality.  Epileptic  spasm  is  not  accom- 
panied by  nor  caused  by  volition,  it  is 
not  volitional  in  kind,  being  far  removed 
from  the  delicate  and  complex  move- 
ments due  to  activity  in  the  co-ordinat- 
ing centres,  and  when  general  and  severe 
it  is  always  accompanied  by  profound 
unconsciousness. 

That  the  great  voluntary  co-ordinating 
centres  in  the  cortex  which  energize  the 
muscles  are  not  roused  to  involuntary, 
unconscious,  and  inco-ordinate  spasm  is 
somewhat  axiomatic  in  its  obviousness. 

Significant  also  is  the  fact  that  the 
speech-centre  is  never  involved  in  con- 
vulsion and  that  disease  of  this  centre 
itself  never  causes  its  epileptic  discharge. 

LESSER  ATTACKS  NOT  CORTICAL. — In 


Convulsive  Seizures  81 

the  case  of  epilepsy  these  facts  find 
confirmation  in  the  development  of  de- 
mentia due  to  exhaustion  and  finally 
permanent  loss  of  function  from  over- 
action  in  the  attacks.  This  loss  of 
function  finds  expression  mainly  if  not 
entirely  in  the  subconscious  apparatus 
of  the  intellect,  and  especially  in  the 
finer  emotional  adjustments  which  are  of 
the  part  of  the  mental  output  called 
character.  This  corresponds  with  the 
fact  that  the  so-called  lesser  attacks 
are  the  more  destructive  of  mentality; 
these  may  be  explosions  of  energy  running 
like  lightning  through  the  subconscious 
intellectual  apparatus  at  the  base  of  the 
brain,  a  part  of  the  nerve  mechanism 
proverbial  for  its  quickness  of  action, 
and  meanwhile  drowning  consciousness, 
as  is  always  the  tendency  of  intense 
protopathic  action. 

CHOREA. — It  may  seem  that  as  the  cor- 
tex is  thus  shown  to  be  capable  of  stimula- 
tion only  by  signals  of  nerve  force  or  its 
analogue  in  the  outer  world,  electricity, 


82     Insomnia  and  Nerve  Strain 

cortical  paroxysms  might  be  set  up  by 
excessive  stimuli  coming  from  the  sensory 
system.  In  fact  this  does  occur.  If  we 
think  of  the  necessary  condition  of 
manifestation  of  such  paroxysms,  it  is 
evident  that  they  must  be  conscious 
and  co-ordinate,  and  the  name  applied 
to  them  is  chorea.  The  closely  allied 
habit  spasms  are  often  caused  by  peri- 
pheral irritants,  and  as  choreic  spasms 
are  evidently  cortical  and  cannot  be 
caused  by  direct  toxic  action,  the  toxic 
locus  morbi  must  be  in  the  basal  ganglia 
or  periphery. 

The  sensory  and  mental  phenomena  oc- 
curring in  chorea  minor  and  its  analogy  with 
habit  spasms  make  a  protopathic  origin 
probable.  Organic  cerebral  disease  asso- 
ciated with  choreic  spasm  is  usually  situ- 
ated in  or  near  the  great  basal  ganglia. 

MECHANISM  OF  EPILEPSY  FROM  CORTI- 
CAL DISEASE. — All  these  phenomena  lend 
color  to  the  belief  that  in  the  basal 
ganglia  the  afferent  sensory  fibres  are 
connected  with  the  motor  centres,  as  in 


Convulsive  Seizures  83 

effect  they  are  shown  to  be  by  reflex 
phenomena,  and  that  the  motor  centres 
are  connected  in  series.  Such  an  arrange- 
ment is  necessary  for  ordinary  combined 
muscular  action,  much  of  which  must  be 
provided  for  in  these  lower  centres. 
The  sensory  centres  on  the  other  hand 
are  not  interconnected,  one  sense-impres- 
sion rarely  setting  up  a  heterogeneous 
percept  and  such  abnormal  percepts 
never  occurring  in  series.  Such  an  ar- 
rangement furnishes  the  explanation  of 
the  single  sensory  and  multiple  motor 
discharge  as  a  response  to  overstimula- 
tion.  The  explanation  of  so-called  corti- 
cal epilepsy  is  in  the  degenerative  process 
which  is  invariably  downward  from  cor- 
tical disease.  Fibres  in  both  motor  and 
sensory  systems  run  in  both  directions 
and  when  degeneration  sets  up  such  irri- 
tation in  the  basal  ganglia  as  to  cause  an 
epileptic  discharge,  it  naturally  begins 
in  the  structures  corresponding  to  the 
cortical  centres. 

To  summarize: — Epileptiform  convul- 
sions invariably  consist  in  discharge  of 


84     Insomnia  and  Nerve  Strain 

the  basal  ganglionic  centres,  and  are 
determined  in  three  ways:  by  irritation 
essentially  degenerative  downward  from 
the  cortex;  by  protopathic  overstimula- 
tion  up  from  the  periphery;  by  toxins 
or  disease  acting  on  the  basal  ganglia 
direct.  The  two  latter  classes  constitute 
the  disease  known  as  epilepsy,  except 
for  cases  in  which  the  cause  is  known, 
as  for  instance  in  those  of  renal  origin. 

VASCULAR  POTENTIAL 

THE  VASO-NEURAL  CIRCUIT. — When 
galvanic  currents  are  applied  to  periph- 
eral nerves  it  is  found  that  centripetal 
currents  increase  and  centrifugal  currents 
dimmish  the  activity  of  the  sensory 
fibres.  It  follows  that  the  normal  sensory 
nerve  currents  are  centripetal,  and  with 
equal  certainty  that  the  sensory  is  a  one- 
way system.  This  means  that  with  the 
battery  in  the  central  ganglia  the  periph- 
eral fibre  is  connected  with  the  negative 
pole  of  the  cell,  and  the  circuit  must  be 
completed  through  other  tissues.  As 


Vascular  Potential  85 

for  the  sensory  and  other  cells  not 
connecting  with  the  periphery  but  with 
different  parts  of  the  brain  there  is 
every  reason  to  think  that  they  are  run 
on  the  same  system. 

It  is  impossible  that  grounding  should 
take  place  normally  through  the  skin. 
The  skin  is  often  dry,  practically  a  non- 
conductor, and  usually  in  contact  with 
the  ground  only  through  the  soles  of  the 
feet. 

The  same  reasoning  applies  with  still 
greater  force  to  the  ganglion  cells  in  the 
brain.  The  skull,  skin,  and  hair  are 
practically  absolute  insulators.  Only  one 
alternative  remains.  The  circuit  must 
be  completed  by  way  of  the  blood- 
stream. 

MOTOR  NERVE-CURRENTS  ARE  CENTRI- 
PETAL. —  In  the  motor  system  it  has 
usually  been  taken  for  granted  that  the 
current  flows  from  centre  to  periphery, 
that  is  centrifugally.  We  know,  however, 
that  normally  cathodal  closure  contrac- 
tion is  greater  than  anodal  closure 


86     Insomnia  and  Nerve  Strain 

contraction,  that  is  the  normal  muscle 
reacts  more  strongly  to  the  negative 
than  to  the  positive  pole  of  the  galvanic 
current.  This  proves  that  the  current 
of  normal  nerve-force  in  the  motor 
fibres  is  negative,  that  is  to  say  the 
motor  like  the  sensory  fibres  are  connected 
with  the  negative  pole  of  the  nerve-cells, 
and  the  positive  current  is  in  the  blood- 
stream. 

INHIBITION  BY  VASCULAR  POTENTIAL. 
— Important  conclusions  follow.  There 
is  here  an  added  reason  for  the  balance 
between  the  epicritic  and  the  protopathic 
systems  in  the  skin.  A  stimulus  in 
reaching  the  protopathic  terminals  from 
without  inevitably  excites  the  epicritic 
system.  Both  systems  discharge  their 
positive  currents  into  the  same  blood- 
stream, and  each  positive  current  escapes 
into  the  blood  less  readily  because  charged 
from  the  other  system.  The  same  state 
of  things  obtains  in  the  brain.  Motor 
and  sensory  cells  alike  discharge  their 
positive  current  in  the  blood,  and  unusual 


Vascular  Potential  87 

activity  in  any  group  of  cells  inhibits 
the  activity  of  all  the  others  by  charging 
the  blood-stream  positively. 

This  makes  possible  a  clearer  concept 
of  the  self -limiting  mechanism  of  pain. 
The  sensory  cells  of  the  cortex  are  small 
and  of  comparatively  low  potential.  High 
vaso-electric  tension  makes  impossible 
their  normal  discharge  into  the  vessels. 
When  a  stimulus,  a  burn  for  example, 
occurs  over  a  small  area  of  the  skin  the 
positive  blood-charge  is  raised,  but  not 
enough  to  interfere  with  cellular  action. 
If  a  large  surface  is  burned,  electric 
tension  is  raised  to  what  may  be  called 
the  anesthesia  point,  or  with  still  greater 
tension  unconsciousness  may  be  caused. 

It  is  difficult,  in  fact  impossible,  to 
carry  on  several  lines  of  thought  at  the 
same  time,  although  thought  and  speech 
are  consistent  with  moderate  activity 
in  the  motor  centres  of  the  arms  and  legs 
which  discharge  into  the  blood  at  some 
distance.  It  is  doubtful,  however,  whether 
any  one  can  carry  on  a  sustained  and 


88     Insomnia  and  Nerve  Strain 

difficult  logical  process  while  running  at 
top  speed.  Inhibition  by  highly  charged 
blood-currents  finds  its  most  striking 
example  in  the  epileptic  paroxysm,  in 
which  severe  general  convulsions  so  in- 
crease electric  tension  in  the  blood  as 
completely  to  inhibit  the  sensory  centres, 
and  unconsciousness  is  the  invariable 
result. 

PARALYSIS  BY  ANEMIA. — When  the 
circulation  is  suddenly  cut  off  from  any 
part  of  the  brain  tissue  by  thrombus  or 
embolism  or  in  any  other  way  the  gang- 
lion cells  in  the  affected  area  instantly 
cease  to  act.  This  is  not  to  be  explained 
by  the  cutting  off  of  their  nutritional 
supply,  which  would  begin  to  affect 
function  after  hours  or  days.  Ganglion 
cells  are  set  in  a  rich  net-work  of  small 
blood-vessels.  When  circulation  is  cut 
off  the  blood  at  once  leaves  the  small 
vessels  and  settles  in  the  veins,  the  cir- 
cuit is  broken,  and  function  ceases  in- 
stantly, to  be  renewed  if  at  all  when 
circulation  is  re-established. 


Vascular  Potential  89 

PARALYSING  EFFECT  OF  COLD. — The 
numbing  effect  of  cold  on  nervous  activity 
also  here  finds  explanation.  Ganglion 
cells  and  nerve  fibres  like  the  galvanic 
battery  should  work  approximately  as 
well  when  cold,  which  excites  but  never 
directly  soothes  nerve  terminals.  We  find 
accordingly  that  cold  as  it  stimulates 
the  epicritic  and  protopathic  end-organs 
acts  as  a  tonic,  and  nervous  energy  is  in- 
creased. When,  however,  it  penetrates 
deeply  enough  to  reach  the  vessels  and  so 
stimulate  them  contraction  results,  the 
part  becomes  bloodless,  and  the  ordinary 
sensory  rheostats  are  deprived  of  their 
connections  with  the  main  blood  stream. 
Hence  anesthesia  results. 

When  the  whole  body  is  chilled  for  a 
sufficient  time  to  lower  the  temperature 
of  the  blood  and  stimulate  the  small 
vessels  about  the  central  ganglion  cells, 
they  contract  and  the  circuit  is  again 
broken,  and  anesthesia,  unconsciousness, 
and  finally  paralysis  and  death  ensue. 

VASCULAR  POTENTIAL  AS  A  CAUSE  OF 


90     Insomnia  and  Nerve  Strain 

FATIGUE. — Fatigue  is  a  phenomenon  that 
may  well  occasionally  bear  an  electric, 
not  entirely  a  toxic,  interpretation.  After 
long  ganglionic  activity  of  any  kind, 
sensory,  motor,  or  mental,  the  blood- 
stream is  highly  charged  positively.  It 
requires  more  vigorous  negative  discharge 
to  overcome  the  resistance.  A  bath, 
especially  a  hot  bath  with  a  following 
cold  shock  and  reflux  of  blood  to  the 
skin,  or  massage,  or  the  neutralizing 
and  stimulating  negative  galvanic  current, 
lowers  positive  vaso-electric  tension  and 
new  energy  may  be  tapped  from  the 
cells  without  undue  effort. 

EFFECT  ON  PLAIN  MUSCLE. — While 
striped  or  voluntary  muscle  is  stimulated 
more  actively  by  the  negative  pole, 
plain  or  unstriped  muscle,  as  it  exists 
in  the  blood-vessels,  stomach,  intestines, 
and  other  viscera,  responds  more  readily 
to  the  positive  pole.  The  phenomena  of 
heart-action  make  it  probable  that  this 
is  also  true  of  the  heart  muscle,  which  in 
structure  seems  to  be  half-way  between 


Vascular  Potential  91 

the  other  two  kinds  of  muscular  tissue. 
The  tendency  then  of  a  high  vascular 
potential  is  to  increase  the  activity  of 
plain  muscle  throughout  the  body. 

When  a  voluntary  muscle  is  entirely 
severed  from  its  connection  with  the 
cerebro-spinal  system,  it  loses  its  tone, 
is  reduced  to  the  condition  of  a  plain 
muscle,  and  gives  corresponding  reactions 
— that  is,  it  reacts  more  vigorously  to  the 
positive  pole  and  with  a  slow  worm-like 
contraction.  This,  however,  does  not 
take  place  until  about  a  week  after  the 
cutting  of  the  nerve-supply — that  is,  until 
the  degenerative  process  has  had  time 
to  creep  down  and  destroy  the  muscular 
end-plate. 

Increased  heart-action  then  and  arterial 
contraction  are  set  up  by  muscular 
exertion,  emotion,  excessive  pain,  or  toxic 
irritation  causing  increase  of  vascular 
potential. 

The  effects  of  sudden  raising  of  the 
potential  of  the  blood-current  on  viscera 
supplied  with  unstriped  muscle  are  well 
known.  Thus  increased  gastric  and  intes- 


92     Insomnia  and  Nerve  Strain 

tinal  activity,  with  vomiting  or  diarrhea, 
may  be  caused  by  emotion  or  pain,  and 
action  of  the  bladder  may  be  induced  in 
the  same  way. 


EFFECT  ON  THE  IRIS. — A  sensitive  index 
of  electric  tension  in  the  vessels,  although 
not  an  uncomplicated  one,  is  furnished 
by  the  iris  supplied  by  radiating — that  is, 
dilating — unstriped  muscular  fibres.  The 
nearness  of  the  eye  to  the  brain  gives  cere- 
bral activity  a  specially  close  connection 
with  the  pupillary  reaction.  During 
sleep  vaso-electric  tension  is  at  its  lowest 
and  the  pupil  is  contracted.  Even 
slight  mental  energy  dilates  it  a  little. 
During  waking  hours  it  is  of  medium 
width,  unless  impact  of  light  on  the 
retina  or  toxic  agents  have  affected  it. 
It  is  dilated  by  unusual  emotion  or 
general  physical  exertion,  and  is  widely 
dilated  during  the  epileptic  paroxysm. 

VASCULAR  POTENTIAL  IN  ACUTE  SHOCK. 
— Crile's  brilliant  researches  have  shown 


Vascular  Potential  93 

that  shock  is  essentially  a  rapid  exhaus- 
tion of  the  forces  of  the  nerve  centres. 
Acute  shock  may  be  denned  as  a  sudden 
intense  disturbance  of  the  vaso-neural 
electric  circuit.  It  may  be  caused  by 
grounding  the  positive  current  in  the 
blood-vessels,  or  by  a  short  circuit  intro- 
duced between  vessels  and  nerves.  From 
what  has  been  said  with  regard  to  the 
reactions  of  the  vascular  system  to  the 
electric  state  of  the  blood,  it  must  be 
evident  that  the  calibre  of  the  vessels 
will  differ  with  the  varying  electric  ten- 
sion in  these  conditions. 

The  painful  results  of  the  short  circuit 
are  recognized  in  the  popular  dread  of 
the  knife  as  compared  with  the  bullet. 
The  slash  is  only  painless  when  quick  as 
light. 

Shock  might  be  largely  avoided  by 
insulated  as  well  as  by  bloodless  surgery ; 
and  the  shock  of  bloody  surgery  is  the 
shock,  not  of  denutrition,  but  of  low- 
ered potential  and  a  broken  vaso-neural 
circuit. 


94     Insomnia  and  Nerve  Strain 

MECHANISM  OF  THE  VASO- 
NEURAL  CIRCUIT 

LOCATION  OF  CLOSURE  OF  THE  CIRCUIT. 
— To  form  an  adequate  idea  of  the  com- 
plete mechanism  of  the  vaso-neural  circuit, 
it  is  necessary  to  consider  ganglion  cells 
with  reference  to  the  points  of  normal  and 
abnormal  closure.  This  has  already  been 
done  in  part  with  regard  to  the  sensory 
system,  the  end -organs  being  rheostats  for 
graduated  closure  of  the  sensory  circuit, 
thus  causing  ganglionic  discharge  propor- 
tional to  the  amount  of  the  irritation. 

It  is  impossible  that  the  motor  circuit 
should  be  closed  at  the  muscle.  The 
motor  ganglion  cell  is  discharged  as  the 
result  of  a  stimulus  imparted  to  it  in  the 
central  organs  by  a  nerve  fibre  com- 
municating with  it  indirectly.  The  cor- 
tical cells  cannot  be  directly  stimulated. 
They  may  be  destroyed  by  any  irritant 
that  causes  an  internal  short  circuit.  The 
only  available  explanation  of  the  failure  of 
direct  stimulation  is  that  the  normal  break 
in  their  circuit  is  in  the  basal  ganglia. 


Vaso-Neural  Circuit  95 

MOTILITY  OF  GLIA  CELLS. — The  sub- 
stance intervening  between  the  inosculat- 
ing processes  constituting  make  and  break 
is  glia  tissue.  The  glia  cells,  then,  inter- 
vening between  the  dendrites  of  the  motor 
cell  and  the  vessels,  or  between  inosculat- 
ing processes  of  fibre  and  cell,  respond  to  a 
stimulus  from  a  sensory  cell  by  a  contrac- 
tion which  narrows  and  elongates  them 
like  an  earthworm,  and  the  connection  is 
thus  made.  This  endows  the  sensory  sys- 
tem with  motor  functions  exerted  on 
the  cells  of  the  glia. 

The  fact  that  cells  cannot  be  stimu- 
lated in  the  cortex  makes  consecutive 
combined  movements  impossible  of  cor- 
tical elaboration.  On  the  other  hand, 
simultaneous  elaborations  may  be  corti- 
cal, a  single  impulse  from  the  base 
being  diffused  among  a  number  of  cells 
along  lines  of  acquired  least  resistance 
of  the  intermediary  glia  cells. 

The  motility  of  the  glia  cells,  then,  like 
that  of  muscular  fibre,  is  dependent  on 
use,  and  ready  and  vigorous  response 
to  stimulation  is  in  proportion  to  the 


96     Insomnia  and  Nerve  Strain 

amount  of  their  previous  exercise,  espe- 
cially recent  exercise.  Functional  nervous 
disease  owes  what  of  permanence  it 
possesses,  apart  from  the  persistence  of 
the  lesion,  to  over-developed  glia  cells 
constituting  abnormal  conducting  paths, 
the  glia  cells  resuming  their  normal  size 
and  activity  gradually  by  rest  after 
removal  of  irritation. 

PAIN  NOT  CORTICAL. — The  fact  that 
sensory  cells  cannot  be  stimulated  in  the 
cortex  makes  it  certain  that  the  stimulant 
closure  of  their  circuit  occurs  lower 
down.  This  enables  us  to  locate  the 
function  of  pain.  If  it  were  registered 
in  the  cortex,  closure  of  the  circuit  by 
basal  disease  would  be  excruciating  agony. 
On  the  contrary,  disease  in  that  region  is 
attended  by  numbness,  tingling,  and  local- 
izing feelings.  Like  emotion,  pain  is  prob- 
ably felt  in  the  basal  ganglia,  and  the  point 
of  its  genesis  by  stimulation  is  lower  down. 

GANGLION  CELLS  NOWHERE  DIRECTLY 
STIMULATED.  —  This  leads  us  to  the 
broader  statement  that  ganglion  cells 


Vaso-Neural  Circuit  97 

can  never  be  directly  stimulated  either 
mechanically,  chemically,  or  electrically. 
An  electric  current  may  be  sent  from  a 
motor  cell  along  the  axis-cylinder  process. 
Easily  leaping  the  glia  cell  to  the  lower 
neuron,  it  stimulates  the  muscle.  The 
effect  of  irritation  in  either  of  these 
three  kinds  on  the  ganglion-cell  itself  is  an 
internal  short  circuit.  The  result  is 
irritation  with  so-called  sedation  and 
final  exhaustion. 

The  reason  for  the  impossibility  of 
discharging  a  ganglion  cell  by  the  direct 
application  of  electricity  will  be  made 
clearer  by  the  following  consideration. 
Suppose  an  ordinary  galvanic  cell  with 
the  carbon  and  zinc  attached  to  wires 
with  terminations  a  sixteenth  of  an  inch 
from  each  other  and  at  some  distance  from 
the  cell.  Functional  discharge  of  the 
cell  is  possible  only  by  the  introduction 
of  a  conductor  between  the  ends  of  the 
wires.  If  the  function  of  the  system  is  to 
ring  a  bell  on  one  wire  situated  on  a  loop 
beyond  the  break  in  the  circuit,  a  connec- 
tion made  between  the  wires  above  the 


98     Insomnia  and  Nerve  Strain 

break  will  short-circuit  the  cell.  Direct 
connection  in  the  cell  between  carbon 
and  zinc  will  result  in  an  internal  short- 
circuit.  If  now  the  current  from  a 
dynamo  be  applied  to  the  cell  or  to 
either  of  the  wires,  as  a  result  the  bell 
may  be  rung,  the  gap  being  ineffective 
for  a  current  of  higher  potential.  The 
only  possible  effect  on  the  cell  itself  is  a 
short-circuit. 

The  cortex,  then,  so  far  as  it  is  known, 
is  a  power  plant  tributary  to  the  main 
electric  system  of  the  base.  It  consists 
of  batteries  and  storage  batteries  actuated 
entirely  from  below. 

NUTRITION  AND  VITALITY 

TROPHIC  CONTROL  BY  VASCULAR 
POTENTIAL.  —  That  vascular  potential 
regulates  trophic  processes  of  the  body 
in  general  is  evident  on  the  following 
consideration. 

When  a  membrane  is  interposed  be- 
tween two  compartments  filled  with  fluid, 
with  a  negative  electrode  in  one  and  a 


Nutrition  and  Vitality          99 

positive  in  the  other  compartment,  while 
the  current  passes  there  is  set  up  a  flow 
of  fluid  through  the  membrane  from  the 
positive  to  the  negative  pole.  These  con- 
ditions are  satisfied  by  both  nerve  cells 
and  glandular  cells  all  over  the  body. 
The  limiting  cell  membrane  separates 
the  contained  protoplasm  from  the  posi- 
tively charged  blood  stream.  As  electric 
tension  rises,  osmosis  is  more  active;  the 
whole  glandular  system  is  thus  electri- 
cally stimulated  by  muscular  or  mental 
activity  or  emotion,  in  degrees  varying 
inversely  with  the  distance  of  the  gland 
from  the  active  nerve  cells,  and  directly 
with  the  amount  of  their  activity.  Thus 
while  nutritional  and  metabolic  processes 
are  under  the  direct  electrical  control  of 
the  nerve  centres  through  the  blood 
stream,  the  ganglion  cells  furnish  alike 
the  current  of  their  functional  activity 
and  their  own  nutrition. 

The  gland  cell,  then,  in  its  proper 
functional  activity  is  an  electro-chemic 
diffusion  apparatus  subject  to  control 
from  a  distance.  Cell  protoplasm 


ioo    Insomnia  and  Nerve  Strain 

apparently  furnishes  the  negative  elec- 
tricity of  the  circuit,  the  nucleus  being 
a  positive  element.  This  may  well  be 
the  primordial  apparatus  of  glandular 
activity,  supplemented  in  the  higher 
animals  by  vascular  potential. 

GENERAL  CONTROL  OF  NUTRITIVE  PRO- 
CESSES.— What  has  been  said  with  regard 
to  glandular  structures  applies  with  equal 
force  to  the  cells  of  the  other  tissues  of 
the  body.  Thus  nutritive  processes  vary 
directly  with  the  general  nervous  activity 
of  the  moment,  and  with  the  richness  of 
capillary  supply,  and  inversely  with  the 
distance  from  the  centres  of  greatest 
electric  activity. 

In  the  nervous  system  the  protoplasmic 
processes  are  so  numerous  as  to  suggest 
that  they  provide  for  the  nourishment 
of  the  ganglion  cell,  as  well  as  closure  of 
the  current  with  the  blood  stream.  Dur- 
ing activity,  osmosis  is  from  within  out- 
ward, the  cell  potential  being  necessarily 
greater  than  that  of  the  blood  stream. 
The  result  is  the  shrunken  cell  of  fatigue. 


Nutrition  and  Vitality         101 

During  rest,  the  potential  of  the  cell  is 
lower  and  osmosis  is  from  without  inward. 


NUTRITION  OF  MUSCLE. — The  problem 
of  nourishment  is  somewhat  different 
with  regard  to  the  three  varieties  of  mus- 
cular fibre.  The  primitive  muscle  is  the 
plain  or  unstriped  variety.  This  is 
sluggish  in  movement,  actuated  by  the 
positive  charge  of  the  blood  stream,  and 
draws  its  nourishment  from  the  blood 
partly  by  its  sluggish  movements,  partly 
by  electric  osmosis  as  do  the  glandular 
structures. 

The  heart  is  much  more  vigorous,  is 
active  from  birth  to  death,  and  needs 
the  maximum  of  nourishment,  which  is 
provided  for  by  its  own  active  movements, 
aided  by  its  more  permeable  striped 
structure  and  by  electric  osmosis  as  well. 

Voluntary  muscle  is  striped  to  allow 
the  maximum  of  nourishment  during 
the  activity  of  the  muscle  cell.  If,  how- 
ever, osmosis  went  on  uninterruptedly 
during  rest,  over-nourishment  would  be 
the  result.  The  end-plate  of  the  nerve, 


102    Insomnia  and  Nerve  Strain 

however,  is  on  the  outside  of  the  muscle 
fibre  and  vaso-electric  connection  is  with 
the  interior  of  the  cell.  This  reduces 
the  difference  between  external  and  in- 
ternal potentials  to  zero,  and  explains 
the  rapid  retrogressive  changes  from 
disuse. 

When  a  peripheral  nerve  is  cut,  vas- 
cular potential  falls  in  the  supplied  area 
either  motor  or  sensory.  The  part  is 
practically  cut  out  of  the  electric  sphere 
of  influence  of  the  body  generally,  and, 
as  is  well  known,  trophic  changes  result 
in  all  of  the  tissues. 

CELL  POTENTIAL  IN  EVOLUTION 

A  consideration  of  vascular  potential  in 
its  developmental  relations  may  be  of  value, 
as  a  basis  for  further  investigation. 

In  unicellular  organisms  specialization 
has  just  begun,  and  is  comparative  with 
non-vital  substances.  The  power  of  as- 
similation, of  sensitiveness  to  impact, 
and  of  comparatively  purposive  move- 
ment are  acquisitions.  The  specific  dif- 


Cell  Potential  in  Evolution    103 

ference,  however,  from  non- vital  matter 
is  the  ability  to  maintain  nutritional  in- 
terchange with  environmental  substances 
by  means  of  a  difference  between  in- 
tracellular  and  extracellular  potential. 
This  is  made  possible  by  electric  activity 
between  nuclear  and  extra-nuclear  proto- 
plasm, the  evolution  of  the  cell  with  its 
nucleus  being  the  anatomic  attribute, 
and  electric  osmosis  the  physiologic  at- 
tribute of  vitality  in  primitive  organisms. 

Physical  osmosis  by  capillarity  and  by 
contractile  movements,  and  osmosis  by 
differences  of  density  are  non-specific 
acquired  powers. 

With  the  acquisition  on  the  part  of 
the  cells  of  more  complex  animals  of 
highly  specialized  powers,  in  the  gland- 
ular tissues  metabolic  power,  in  plain 
muscle  contractile  power,  and  so  on, 
there  is  in  most  tissues  retention  of  spe- 
cific electric  function  in  the  same  sense; 
that  is,  the  maintenance  in  cell  proto- 
plasm of  negative  potential  as  compared 
with  extra-cellular  and  intra-nuclear  posi- 
tive potential. 


104    Insomnia  and  Nerve  Strain 

In  the  evolution  of  the  ganglion-cell 
and  the  correlated  striped-muscle  tissue, 
a  specific  difference  from  lower  grade  tis- 
sues is  introduced. 

The  structure  of  the  ganglion  cell  indi- 
cates the  electric  continuity  of  the  axis- 
cylinder  process  with  the  nucleus,  and 
of  the  protoplasmic  process  with  the  cell 
body.  We  have  already  seen  that  the 
axis  cylinder  is  connected  with  the  nega- 
tive, and  the  dendrites  with  the  positive 
pole  of  the  cell.  This  is  the  reverse  of 
the  formula  of  polarity  of  the  lower 
tissues. 

In  striped  muscle,  by  the  electric  con- 
nection of  the  blood  stream  with  the  in- 
terior of  the  cell,  there  is  no  difference  of 
potential  between  cell  and  blood,  and 
osmosis  is  not  electric,  but  only  mechan- 
ical and  chemical. 

The  specific  difference,  then,  between 
ganglion  cells  and  lower  cells  in  general  is 
in  the  reversal  of  polarity ;  the  distinguish- 
ing feature  of  striped  muscle  is  the  neu- 
tralizing of  polarity. 

Nutritive  processes  go  on  in  ganglion 


Epicritic  Neuro- Psychoses     105 

cells  practically  only  during  rest,  in 
striped  muscle  practically  only  during 
activity;  while  in  other  tissues  functional 
and  nutritive  processes  are  alike  practi- 
cally continuous,  being  less  active  during 
sleep  only  by  reason  of  the  lowering  of 
vascular  potential. 

Vitality  may  be  said  to  consist  in  the 
ability  of  an  organism  to  maintain  a  dif- 
ference of  potential  sufficient  to  carry 
on  nutrition  by  electric  osmosis.  It  is 
a  power  inherent  in  most  or  all  cells  and 
specialized  in  the  ganglion  cells. 

The  conclusion  seems  warranted  that 
nerve  force  and  electricity  are  related 
by  identity  rather  than  by  likeness. 

EPICRITIC  NEURO-PSYCHOSES 

HYSTERIA. — Of  the  lesions  thus  far 
considered,  neuroses  and  psychoses  alike 
are  primarily  lower-level  disorders,  and 
in  them  the  cortex  is  implicated  only 
secondarily.  There  remains  one  of  the 
most  complex  of  the  functional  disor- 
ders and  one  which  has  long  been  the 


106   Insomnia  and  Nerve  Strain 

subject  of  careful  study,  namely,  hysteria. 
Its  symptoms,  while  often  disturbances 
of  vegetative  life,  concern  themselves 
about  equally  with  the  emotions  and  with 
the  perceptive  functions  and  highest 
mental  activities  of  the  cortex,  conscious- 
ness, attention,  and  volition.  The  short- 
est possible  statement  must  here  suffice 
of  the  hysteric  symptom-complex  in  its 
relations  with  the  nervous  mechanism. 

The  characteristic  feature  of  the  hys- 
teric symptom-complex  lies  in  the  ease 
of  conjunction  and  disjunction  of  the 
ganglionic  centres,  both  conscious  and 
subconscious,  together  with  abnormal 
activity  of  the  centres. 

It  is  not  necessary  to  suppose  unusual 
power  on  the  part  of  the  ganglion  cells 
themselves.  There  is  rather  an  unusual 
completeness  of  connection  of  the  vaso- 
neural  circuit  as  well  as  between  the 
nerve  centres,  with  correspondingly  rapid 
exhaustion  of  nervous  energy.  Volition 
and  self-consciousness  have  an  undue 
share  in  the  abnormal  condition,  and  are 
worthy  of  special  consideration. 


Epicritic  Neuro- Psychoses     107 

Self -consciousness  is  the  highest  appli- 
cation of  formal  thought  to  the  processes 
of  ideated  sensation  and  vivified  idea, 
resulting  in  cognition  of  mental  per- 
sonality, distinguished  from  physical 
identity,  as  a  partly  inherent,  partly 
habitual  mode  of  operation  of  percept 
and  thought  in  a  special  and  delimited 
nerve-mechanism. 

A  voluntary  act  is  one  to  whose  pro- 
duction the  highest  mental  functions, 
consciousness  and  formal  thought,  have 
contributed.  Volition  so  far  as  it  exists 
within  the  limits  of  cognition  is  a  feeling 
of  freedom  of  choice  and  to  a  greater  or 
less  degree  a  feeling  of  effort  accompany- 
ing certain  conscious  movements  of  the 
soma,  operations  of  the  psyche,  and  selec- 
tive movements  of  attention. 

Certain  limitations  of  the  will  are  sub- 
jectively recognized,  comprising  acts 
carried  out  by  the  lower  motor  centres, 
thoughts  that  seem  to  come  into  the 
mind  spontaneously  and  attention 
compelled  by  sensation  overmastering 


io8    Insomnia  and  Nerve  Strain 

memory  and  thought.  The  dominance 
of  ideated  sensation  is  also  subjectively 
recognized,  either  as  the  spoken  word 
compelling  and  determining  ganglionic 
activity,  or  the  power  of  circumstance 
acting  through  consequent  emotions.  It 
is  this  dominance  of  ideated  sensation  in 
either  of  its  forms  that,  normally  present 
in  all  men,  when  abnormal  in  degree  is 
the  essential  feature  in  hysteria. 

MOTILITY  OF  THE  GLIA  IN  HYSTERIA. — 

Predisposition  to  hysteria  consists  in  an 
original  or  acquired  ease  of  disjunction 
of  certain  paths  of  communication  between 
cortex  and  basal  ganglia.  The  hysteric 
may  thus  be  capable  of  mental  activity 
of  high  grade,  but  has  an  instability 
between  conscious  and  unconscious  men- 
tality. Hysteric  symptoms  result  from 
shocks  or  suggestions  breaking  the  con- 
nections just  mentioned.  It  is  apparent 
that  hysteria  has  affiliations  with  both 
hypnotism  and  ordinary  sleep. 

Unusual  activity  of  association  between 
percepts  and  memories  on  the  one  hand, 


Epicritic  Neuro- Psychoses     109 

and  the  protopathic  system  on  the  other, 
brings  the  hysteric  into  strong  touch  with 
the  wills  of  others,  and  the  result  is  a 
protopathic  system  dominated.  In  the 
genius,  in  whom  the  power  of  concentra- 
tion is  unusually  developed,  the  intrinsic 
faculty  of  formal  thought  is  stronger. 

Clinically  hysteria  may  be  provisionally 
defined  as  a  state  of  abnormally  height- 
ened consciousness  subject  in  unusual 
degree  to  abstraction  from  certain  fields 
and  increased  attention  to  others  under 
the  influence  of  protopathic  and  epicritic 
forces  alike  extrinsic  and  intrinsic.  The 
diminution  and  heightening  of  activity 
in  the  cortex  result  in  nerve  currents 
which  follow  the  lines  of  least  resistance, 
in  the  higher  psycho-motor  centres,  or 
downward  to  the  sensory  and  emotional 
mechanism  of  the  base.  Unusual  length 
and  motility  of  the  glia  cells  such  as  are 
here  supposed  explain  the  equal  suscep- 
tibility of  hysteric  subjects  to  psychic 
and  physical  shocks. 

It  is  easy  to  see  that  when  disjunction 
occurs  from  concussion  or  from  a  strong 


1 10    Insomnia  and  Nerve  Strain 

sensory  impression,  physical  recovery  of 
the  glia  may  in  time  be  practically 
complete,  and  a  mental  impression  be  at 
last  the  means  of  forcing  a  current  through 
the  re-established  pathway. 

Disjunction  then  in  the  hysteric  may 
be  a  local  phenomenon  resulting  in 
anesthesia  or  paralysis,  or  approximation 
of  the  mobile  glia  may  result  in  hyperac- 
tivity  either  motor  or  sensory.  More 
general  disjunction,  especially  by  hyp- 
notic suggestion,  may  plunge  the  hysteric 
into  sleep  at  times  profound,  but,  like 
ordinary  sleep,  consistent  with  the  main- 
tenance of  certain  communicating  paths 
and  much  cortical  activity. 

I  am  inclined  to  class  hysteria  tenta- 
tively as  an  epicritic  disease.  Its  symp- 
toms are  largely  in  the  epicritic  field, 
voluntary  convulsions,  spurious  coma, 
and  imitative  diseases.  Its  precipi- 
tating cause  is  often  epicritic,  either 
ideated  sensation  or  the  spoken  word. 
Its  cause  may  be  protopathic,  as  the 
exciting  cause  of  protopathic  disease 
may  be  epicritic. 


Prognosis  1 1 1 

Hallucinatory  insanity  and  paranoia 
are  epicritic  in  manifestation.  I  have 
made  no  observations  in  regard  to  the 
location  of  possible  irritants  in  these 
cases.  Provisionally  they  may  be  classed 
as  epicritic  psychoses. 

PROGNOSIS 

In  the  preceding  sections  we  have  gone 
far  by  deduction  to  gain  some  idea  of 
nervous  interaction.  Such  considera- 
tions are  of  moment  in  proportion  with 
their  ultimate  bearing  on  the  concrete 
phenomena  of  disease,  and  hope  of  cure. 

The  outlook  for  recovery  from  any 
disease  is  in  proportion  not  only  with 
the  chance  of  spontaneous  removal  of 
irritation  and  nutritive  repair,  but  with 
the  possibility  of  aiding  these  processes 
on  a  basis  of  adequate  diagnosis. 

Among  the  diseases  here  set  down 
there  is  one  that  has  no  single  redeeming 
feature.  Many  epileptics  have  long  inter- 
vals of  normal  activity;  maniacs  have 
the  joy  of  their  disease;  the  demented 


ii2    Insomnia  and  Nerve  Strain 

have  at  least  euphoria,  lapsing  with 
the  revolving  years  into  the  final  mercy, 
euthanasia;  but  a  little  melancholy  is  a 
little  curse  and  a  great  melancholy  is 
torture  indescribable.  Of  this  one  disease, 
subjectively  at  any  rate  the  worst  of  all, 
it  may  be  said  that  it  is  often  not  only 
recoverable  but  curable,  absolutely  and 
by  procedure.  This  follows  from  the 
many  cases  of  recovery  prompt  on  the 
heels  of  definitive  protopathic  relief. 
Most  of  these  patients  are  permanently 
cured,  the  earliest  of  those  here  set  down 
being  at  this  writing  well  for  fifteen  years 
and  more. 

In  regard  to  mania,  indications  by 
analogy  and  direct  experience  supplement 
the  present  recorded  cases  and  indicate 
the  same  result  of  cure.  The  same  may 
be  said  even  of  dementia  precox. 

Patients  apparently  demented  for  years, 
the  cog-wheels  of  the  memory  to  all 
appearance  thrown  permanently  out  of 
gear,  often  finally  rouse  and  return  to 
normal  life.  Noteworthy  is  the  fact 
that  most  of  the  patients  studied  by 


Prognosis  113 

Kraepelin  in  his  great  work  on  Manic- 
depressive  Insanity,  and  scheduled  by 
him  as  hopelessly  demented,  eventually 
recovered  after  many  years.  The  number 
of  memories  in  use  by  an  individual 
at  a  given  time  is  almost  infinitesimal 
compared  with  those  that  are  inactive. 
Attention  may  be  withheld  from  any 
group  of  memories  by  the  activity  of 
attention  given  to  another  group,  or  may 
be  abstracted  from  the  higher  memories 
entirely,  by  abnormal  activities  in  the 
protopathic  structures  at  the  base.  That 
on  the  recovery  of  protopathic  health 
memory  is  regained  is  in  accord  with 
what  we  know  of  facts  relating  to 
memory  in  other  conditions. 

The  number  of  spontaneous  or  rather 
accidental  recoveries  recorded  from  time 
to  time  have  been  enough  to  indicate 
the  possibility  of  a  lesion  curable  if 
found.  Significant  lesions  in  abundance 
have  been  already  found  by  skiagraph 
in  many  of  the  cases  here  described  and 
indications  of  more  are  to  be  had  for 
the  seeking.  The  lesions  have  been 


H4    Insomnia  and  Nerve  Strain 

removable,  and  analogy  with  the  results 
attained  in  other  groups  of  cases  beats 
a  broad  path  of  probability  of  a  success- 
ful issue  here  also,  to  measures  thought- 
ful in  their  adequacy  and  vigorous  in 
execution. 

Of  insomnia  it  may  be  said  that  it  is  a 
symptom,  the  most  tractable  of  all, 
whether  it  goes  hand  in  hand  with  mental 
aberration  or  in  association  with  the 
mildest  indications  of  the  neurosis  of 
fatigue.  This  tractability  is,  however, 
absolutely  conditioned  on  removal  of 
continuing  irritations. 

The  other  diseases  under  consideration 
are  known  to  be  curable  in  varying 
proportion,  the  more  if  their  cause  is 
known. 

THERAPY. 

The  neuro-psychoses  are  in  part  toxic 
in  origin.  To  understand  the  symptoms 
and  the  methods  of  their  cure  it  is 
necessary  to  consider  in  brief  the  ration- 
ale of  the  selective  action  of  poisons  on 


Therapy  115 

the  nervous  system,  especially  the  alco- 
hols, ethers,  and  alkaloids. 

DRUG  ACTION.  —  Two  striking  and 
recently  observed  instances  of  such 
selection  are  the  local  anesthetic  effect, 
which  really  means  the  peripheral 
anesthetic  effect  of  cocain,  and  the 
comparative  actions  of  the  sulfonal 
group,  practically  pure  hypnotics,  and 
of  the  antipyrin  group,  practically  pure 
sedatives  of  pain. 

The  effect  of  the  latter  group  on  tem- 
perature is  too  obscure  for  present  con- 
sideration and  will  be  ignored.  A  com- 
parison of  the  developmental  reasons  for 
the  differences  between  their  actions  and 
those  of  the  alcohols  and  ethers  gives  a 
clue  to  the  location  and  probable  reason 
for  the  location  of  action  of  these  several 
toxic  substances. 

The  lowest  animals  to  develop  a  heart 
with  a  nervous  mechanism  of  stimulation 
were  small  creatures  and  soft,  penetrable 
throughout  by  the  ordinary  products  of 


n6    Insomnia  and  Nerve  Strain 

fermentation  and  decay,  alcohols  and 
ethers.  Their  life  depended  on  the  de- 
velopment of  nervous  tissue  resistant  to 
the  sedative  action  of  these  substances; 
such  resistance  is  not  absolute  but  exists 
to  a  comparatively  high  degree.  Later 
respiration  was  developed,  aerial  and 
aqueous,  carried  on  by  a  nervous  mechan- 
ism of  somewhat  feebler  resisting  power. 
The  general  protopathic  system,  the 
penalty  of  whose  temporary  sedation 
is  not  the  instant  death  of  the  whole 
organism,  became  endowed  with  a  selec- 
tive resistance.  The  deeply  situated 
ganglion  cells  are  less  resistant  to  the 
sedative  action  of  these  omnipresent 
poisons.  The  end-organs,  whose  useful- 
ness lies  in  their  excitability,  are  stimu- 
lated alike  by  wounds,  heat,  pressure, 
even  by  these  erstwhile  toxic  sedatives. 
The  later  epicritic  system,  with  its 
receiving  centres  in  the  cortex  and  signal- 
stations  in  the  skin,  presents  a  curious 
deviation  from  the  action  of  its  proto- 
pathic relative.  The  action  of  the  alco- 
hols and  ethers  on  the  cortex  is  surely  by 


Therapy  1 1 7 

sedation,  or  what  is  the  same  thing,  irrita- 
tion and  consequent  exhaustion. 

The  fact  that  the  active  principle 
of  the  leaf  of  one  plant  and  that  of  limited 
habitat,  the  erythroxylon  coca,  should 
have  the  unusual  power  of  sedation  of 
the  sensory  terminals,  shows  that  the  re- 
sistance of  these  to  the  early  sedative 
power  of  alcohols  and  ethers  is  a  protective 
acquirement,  the  unfit  having  early  per- 
ished by  intoxication. 

Purely  artificial  products  of  the  labora- 
tory, such  as  the  anilin  derivatives,  form 
a  class  by  themselves.  Their  only  evo- 
lutionary relations  are  by  indirection 
through  their  similarity  with  natural 
products.  Accordingly  the  known  seda- 
tives epicritic  by  preference  are  few ;  that 
is,  the  drugs  with  the  function,  useless  in 
nature,  of  soothing  the  cortex  before 
acting  on  the  lower  centres  are  antipyrin, 
phenacetin,  and  other  similar  products 
of  the  laboratory.  The  sulfonal  group, 
on  the  other  hand,  are  first  of  all  proto- 
pathic  sedatives.  They  are  powerless  to 


n8    Insomnia  and  Nerve  Strain 

control  processes  of  cognition,  either 
of  nerve  pain  or  genuine  mental  distress. 
The  vague  activities  that  bring  insomnia 
and  melancholy  out  of  the  subconscious 
ego  they  may  quiet,  and  this  they  do 
first. 

This  leads  to  the  final  generalization 
in  regard  to  drug  action.  Drugs  in  so 
far  as  they  affect  nerve  tissue  act  on  it 
invariably  by  irritation,  as  do  mechani- 
cal agents.  Some  nerve  tissues  are 
awakened  to  functional  activity  by  such 
action,  in  others  that  activity  is  impeded 
by  the  irritation,  this  constituting  so- 
called  sedative  action.  The  difference 
between  stimulation  and  sedation  is  the 
difference  between  closure  of  the  circuit 
and  short-circuit. 

This  is  not  to  say  that  either  an  internal 
or  external  short  circuit  of  a  ganglionic 
battery  may  not  under  some  circum- 
stances be  beneficial.  Its  conditions  of 
usefulness  are  problems  alike  for  the 
pharmacologist  and  clinician. 

COUNTER-IRRITANTS      AND      DIFFUSE 


Therapy  119 

IRRITANTS. — In  treatment  it  should  ever 
be  borne  in  mind  that  results  are  not 
simply  in  quantitative  proportion  to  the 
nerve  flow.  Disaster,  when  not  due  to 
an  overwhelming  quantitative  loss, 
usually  comes  from  high-tension  escape 
from  a  single  point,  or  escape  at  a  point 
where  undesirable  lines  of  least  resistance 
have  been  established. 

High-tension  escape  may  be  controlled 
or  alleviated  by  ordinary  counter-irrita- 
tion or  by  diffuse  irritation. 

One  of  the  most  efficient  means  of 
distributing  irritation  generally  over  the 
protopathic  terminals,  thus  lowering  ten- 
sion and  diminishing  loss  at  a  special 
point,  is  by  the  use  of  alcoholic  drinks. 
As  alcohol  produces  at  some  times  elation 
and  at  other  times  depression,  and  the 
tendency  in  psychic  cases  is  to  excess, 
with  consequent  over-stimulation  and 
eventual  visceral  disaster,  its  use  should 
be  discouraged  as  dangerous. 

A  safer  method  is  by  laxatives. 
Protopathic  intestinal  activity  tends  in 


120    Insomnia  and  Nerve  Strain 

general  to  euphoria,  largely  by  the 
elimination  of  irritant  poisons. 

If  irritating,  however,  laxatives,  like 
other  protopathic  stimulants,  quite  rarely 
produce  melancholy  instead  of  elation. 

In  case  of  either  mania  or  melancholia, 
in  fact  of  any  neuro-psychosis  from  a 
local  protopathic  irritant  outside  the 
gastro-intestinal  tract,  a  laxative  relieves 
by  the  counter-irritant  action  of  the 
diversion  of  sensory  nerve-currents.  In 
case  of  nervous  symptoms  from  intes- 
tinal stasis,  laxatives  relieve  by  removal 
of  the  irritant  poisons.  These  various 
phenomena  may  in  part  account  for  the 
well  known  clinical  fact  that  purgation 
is  good  for  almost  anything;  it  is  in 
fact  the  great  protopathic  regulator. 

Purgation  is,  however,  not  available 
indefinitely.  Stomach  and  intestines  fin- 
ally rebel.  The  skin  is  a  more  patient 
organ,  and  a  seton  may  be  efficient  after 
years  of  useful  activity. 

CLIMATE  AND  BATHS. — General  stimula- 
tion of  the  skin  not  only  diminishes 


Therapy  121 

protopathic  strain,  it  induces  widespread 
epicritic  activity  as  well.  Not  only  such 
measures  as  hot  and  cold  baths,  the  salt 
glow,  and  the  electric-light  cabinet  have 
this  effect,  but  a  sojourn  in  some  land 
of  sunshine  keeps  the  skin  stimulated, 
especially  if  the  clothing  be  light-colored. 
This  is  an  expedient  to  be  used  with 
caution  in  cases  of  nerve  strain.  Tension 
is  taken  off  for  a  time  by  the  continuous 
flow  of  nerve  currents  in  the  skin,  but 
this  relief  is  later  succeeded  by 
exhaustion. 

The  diffuse  nerve  flow  for  a  time 
removes  fatigue  and  gives  a  sense  of 
vigor,  as  does  a  salt  rub  or  a  hot  bath. 
Not  under  control  like  ordinary  thera- 
peutic measures,  motor  exhaustion  and 
sensory  irritability  are  apt  to  ensue 
in  the  neurotic  and  finally  even  in  those 
tolerably  strong,  with  insomnia,  which 
may  indeed  be  an  early  symptom. 

In  the  tropics  even  more  than  in 
sunny  lands  like  Arizona,  conditions  favor 
nerve  flow,  and  with  very  different  results. 


122    Insomnia  and  Nerve  Strain 

For  instance  at  Singapore  where  the 
thermometer  never  goes  above  eighty- 
five  and  the  air  is  always  near  the  dew- 
point,  with  almost  one  hundred  per  cent. 
of  contained  moisture,  languor  and  ex- 
haustion are  so  great  that  it  is  dangerous 
to  walk  abroad  in  the  middle  of  the  day, 
and  sunstrokes  are  frequent.  This  differ- 
ence from  Arizona,  where  with  a  summer 
heat  of  1 10°  or  1 1 5°  sunstroke  is  unknown, 
is  striking.  The  clinical  thermometer 
does  not  show  that  in  the  drier  climate 
body  heat  is  kept  lower  by  evaporation. 
Nerve  waste,  however,  proceeds  on  very 
different  lines.  The  moist  skin  freely 
taps  the  comparatively  deep  potential  of 
the  blood  stream  through  a  skin  con- 
stantly soaked  by  the  saline  product  of 
the  sweat  glands. 

The  use  of  baths  should  be  governed 
by  the  capacity  of  the  individual  to 
react.  This  depends  on  the  integrity  of 
the  vaso-motors,  and  this  again  largely 
on  the  degree  of  their  protection  by  fat. 
In  thin  people  undue  contraction  of  the 
vessels  occurs,  and  vascular  potential 


Therapy  123 

is    rapidly    lowered,    with    consequent 
exhaustion. 

SUGGESTIVE  THERAPY. — In  civilized 
man  the  spoken  word  affects  the 
protopathic  symptom  powerfully  for 
both  good  and  ill.  Suggestive  therapy 
is  usually  powerless  to  affect  a  proto- 
pathic system  stimulated  and  attention 
diverted  by  a  severe  physical  irritant. 
The  wide  application,  however,  and  gen- 
erally beneficial  effect  of  this  form  of 
treatment  in  its  various  modes  of  appli- 
cation are  well  recognized  in  combating 
the  annoying  and  disabling  symptoms 
of  the  moderate  cases. 

Physical  disorders  lie  especially  open 
to  the  action  of  faith  and  argument,  and 
the  mysterious  but  familiar  powers  of  an 
extrinsic  personality.  Pain  may  be  over- 
come, confidence  restored,  vitality 
stimulated. 

The  mentally  afflicted,  however,  meet 
persuasion  with  argument,  they  beat 
down  hope  with  despair,  and  in  the  worst 
cases  oppose  to  all  psychic  measures 


124    Insomnia  and  Nerve  Strain 

the  impenetrable  defence  of  a  soul  with- 
drawn and  inaccessible. 

INTENSIVE  TREATMENT. — The  maxi- 
mum effect  on  disease  is  attained  by 
primary  eradication  of  the  cause  and 
simultaneous  moral  uplift  and  general 
improvement  of  physique.  The  improve- 
ment attained  by  one  of  these  means 
alone  increases  in  geometric  ratio  with 
the  addition  of  the  other  two. 

The  most  brilliant  plan  of  treatment 
in  this  wise  is  Dr.  Weir  Mitchell's  rest 
cure.  By  his  device  forced  feeding 
builds  up  the  insulations  of  the  brain 
and  cord  and  surrounds  the  terminals 
of  the  skin  and  the  subcutaneous  vessels 
with  non-conducting  fat.  Massage  and 
electricity  ensure  enough  discharge  both 
motor  and  sensory  to  keep  nerve  tension 
low.  Isolation  prevents  psychic  shocks; 
a  cheerful  nurse  to  read  to  the  patient 
and  otherwise  divert  him  prevents  the 
nerve-waste  of  fretting  and  homesickness, 
and  Dr.  Mitchell's  own  patients  have  the 
uplift  of  his  commanding  personality. 


Predisposition  and  Heredity  125 
PREDISPOSITION  AND  HEREDITY 

PREDISPOSITION  TO  NERVOUS  DISEASE. 
— The  neuropsychoses  in  general  may  be 
defined  as  conditions  of  nerve  waste  from 
excessive  irritation,  usually  protopathic, 
accompanied  by  phenomena  of  disor- 
dered nerve  action.  The  particular  phe- 
nomena are  determined  by  lines  of 
original  or  acquired  least  resistance  in  the 
nervous  system  and  may  be  sensory, 
motor,  or  psychic. 

Neurotics  are  those  in  whom  pro- 
tective insulations  have  been  more  or  less 
weakened  or  broken  down.  The  neurotic 
tendency  is  constituted  by  original  weak- 
ness of  protective  insulations  or  acquired 
abnormal  activity  on  the  part  of  the  con- 
necting glia. 

So  far  as  predisposition  to  the  neuro- 
psychoses is  nervous,  it  manifests  itself 
in  two  ways;  by  unusual  sensitiveness  to 
the  action  of  irritants,  shown  by  undue 
sensory  and  emotional  reaction;  and  by 
unusual  susceptibility  to  exhaustion  from 


i26    Insomnia  and  Nerve  Strain 

consequent  overact  ion.  Patients  in  whom 
the  first  kind  of  predisposition  predomi- 
nates are  prone  to  mania,  melancholia, 
and  various  neuroses;  those  in  addition 
readily  exhausted  develop  terminal  de- 
mentia or  dementia  precox. 

Delicacy  of  emotional  reaction  can 
hardly  be  considered  degenerate.  It  is 
in  no  sense  atavistic,  being  conspicuously 
absent  in  the  lower  races,  and  is  rather  a 
mark  of  the  finer  adjustment  to  his 
environment  characteristic  of  civilized 
man,  than  of  a  return  to  a  lower  and 
coarser  type. 

There  is  another  mode  of  nervous 
reaction  that  may  be  considered  degen- 
erate, the  reaction  of  too  great  resistance. 
Robust  persons  may  be  nervously  so 
immune  to  toxins  as  to  suffer  corrosion 
and  sclerosis  from  suppurative  or  alco- 
holic intoxicants,  ending  in  death,  with 
no  nervous  reactions  to  indicate  its 
approach.  A  railroad  with  red  lights 
so  delicately  set  as  to  flash  out  on  the 


Predisposition  and  Heredity  127 

rumble  of  every  passing  cart  might  be 
said  to  suffer  from  over-refinement  in  its 
signal  department.  It  would,  however, 
have  advantages  over  a  road  with  signals 
still  dark  and  the  train  in  the  ditch. 

NEURO-PSYCHOSES  NOT  DEGENERATE. 
— In  the  matter  of  the  significance  of  the 
so-called  stigmata  of  degeneracy  it  is 
interesting  to  study  the  countenances 
of  one's  friends.  There  may  be  noted 
among  them  the  occasional  irregular 
teeth,  slanting  Mongolian  eyes,  asymmet- 
ric faces,  adherent  ear-lobes,  and  all  the 
other  signs  and  omens.  Confront  these 
physical  conditions  with  their  mental 
and  moral  qualities.  The  upright  mind, 
level  head,  kind  heart,  and  playful  de- 
meanor are  amply  compatible  with  what 
are  called  the  physical  attributes  of  de- 
generacy. In  the  asylums  note  that 
insanity  is  like  sanity  impartially  dis- 
tributed among  people  with  and  without 
stigmata. 

The  idea  suggests  itself  that  a  stigma 


1 28    Insomnia  and  Nerve  Strain 

becomes  important  in  the  etiology  of 
insanity  only  when  it  is  at  once  a  stigma 
and  a  lesion,  as  is  the  case  with  an  im- 
pacted tooth.  This  being  granted,  the 
explanation  of  heredity  of  the  neuro- 
psychoses is  at  once  in  hand.  They  are 
hereditary  as  headaches  are  hereditary, 
never  by  the  symptom  but  by  the  vis- 
ceral lesion,  the  sagging  kidneys,  inactive 
stomach,  astigmatic  eyes,  crowded  or 
impacted  or  decayed  teeth.  The  symp- 
toms follow  according  to  the  pathologic 
equation  of  the  individual  as  headaches, 
habit  spasm,  epilepsy,  melancholy,  mania, 
or  in  presence  of  the  tremendous  irrita- 
tion of  impaction,  even  dementia  precox. 

Predisposition,  then,  to  the  neuro- 
psychoses is  of  two  kinds,  nervous  and 
visceral.  Nervous  predisposition  consists 
in  weakness  or  irregularity  of  the  insulat- 
ing tissues,  or  more  often  an  overdevelop- 
ment of  glia  cells  with  resulting  abnormal 
paths  of  communication,  and  may  be 
either  hereditary  or  acquired.  Visceral 
predisposition  consists  in  proneness  to 


Predisposition  and  Heredity  129 

visceral    disease,     and    may    be    either 
hereditary  or  acquired. 

There  is  a  distinct  value  which  may 
attach  to  the  materializing  tendency  of 
the  theory  now  advanced.  Whatever 
may  be  thought  of  the  inner  meaning  of 
the  so-called  physical  stigmata,  there  is 
another  stigma  adherent  to  insanity,  the 
odium  of  a  disease  that  brutalizes  and 
that  flows  to  posterity  through  the  blood. 
If  it  can  be  shown  that  this  heredity  is 
not  a  slimy  ancestral  current  descending 
to  engulf  the  soul,  but  something  limited 
and  palpable,  no  worse  a  blemish  than  a 
tumor  or  a  gangrene,  something  will  have 
been  done  in  the  asylums  for  the  comfort 
of  those  who  wait  without  the  walls. 


APPENDIX 
DENTAL  LESIONS 

the  viscera  responsible  for  the  more 
obscure  cases  of  nervous  and  men- 
tal derangement  I  have  no  hesitation  in 
designating  the  teeth  as  the  most  import- 
ant. This  is  not  only  on  account  of  the 
common,  almost  universal  occurrence 
of  dental  diseases,  but  because  these 
organs  move,  during  the  period  of  their 
development,  through  the  solid  frame- 
work of  the  jaw,  highly  innervated  and 
clothed  by  a  membrane  sensitive  to 
impact  and  to  corrosive  toxins. 

The  two  most  important  lesions,  im- 
paction  and  abscess,  are  both  of  them  in 
some  cases  obvious  to  inspection,  but 
usually  they  can  only  be  discovered  by 
skiagraph.  Impactions  may  be  in  any 
region  of  the  jaw.  They  may  be  indi- 
cated with  some  probability  by  a  gap 
131 


132    Insomnia  and  Nerve  Strain 

where  the  missing  tooth  should  be,  but 
such  a  gap  is  by  no  means  conclusive. 
An  extraction  may  have  been  made  and 
forgotten,  or  teeth  fail  to  develop,  leav- 
ing a  gap  or  a  temporary  tooth  persistent 
sometimes  for  years. 

The  presence  of  all  the  teeth  in  their 
proper  place  is  not  conclusive  against 
impaction,  as  is  shown  by  an  occasional 
fourth  molar. 

Inspection  is  in  many  cases  inadequate 
to  show  abscess  at  the  roots  of  a  tooth. 
In  some  cases  the  pus  finds  its  way  out 
between  the  tooth  and  the  gum,  but  ab- 
scesses may  persist  for  years,  undermining 
mental  health  or  physical  strength,  with- 
out pain  or  other  localizing  sign  of  their 
presence. 

The  skiagraph  is  only  capable  of  show- 
ing absorption  of  bone,  and  pus  may  be 
present  for  a  time  without  this,  but  in 
most  cases  within  a  few  weeks  or  months 
after  development  of  an  abscess  the  skia- 
graph shows  in  the  negative  a  dark  area 
of  absorption.  The  germs  find  their  way 
to  the  roots  of  the  tooth,  usually  through 


CASE     2.— Insomnia.    Alveolar  CASE  4.— Melancholy.  Alveolar 

abscess.       Lower     molar     tooth.       abscess.   First  molar  tooth.    Roots 
Roots  partly  absorbed.  partly  absorbed. 


CASE    3. — Renal  and  Vascular  Disease.     Multiple 
abscesses  in  both  upper  and  lower  jaws. 


Case  of  Albuminuria  with  cardiac  and  vascular 
symptoms.  Complete  nervous  breakdown  of  five 
years'  standing  Multiple  abscesses  in  both  upper 
and  lower  jaws. 


Appendix  133 

the  pulp  chamber,  as  a  result  of  decay,  but 
may  be  carried  by  material  used  in  filling 
the  root  canals.  Abscess  sometimes  de- 
velops, however,  about  a  tooth  dead 
though  not  decayed. 

A  distinction  should  be  made  between 
an  alveolar  abscess  and  an  ulcerated  tooth. 
When  an  abscess  at  the  root  of  a  tooth 
follows  the  peridental  membrane  to  the 
surface  and  involves  the  soft  tissues,  the 
tooth  is  popularly  said  to  be  ulcerated. 
This  is  a  comparatively  harmless  process, 
as  pain  and  swelling  make  the  difficulty 
an  obvious  one.  With  the  evacuation  of 
the  pus  the  soft  tissues  recover  but  the 
abscess  remains  in  the  bone,  noxious  but 
inevident. 

The  object  of  dentistry  is  the  conserva- 
tion of  the  tooth,  for  mastication  and 
ornament.  Dead  teeth  were  formerly 
filled,  the  main  pulp  chamber  being 
plugged  and  the  roots  left  open.  It  was 
found  that  abscess  was  practically  invari- 
able in  the  course  of  some  years  at  the 
roots  of  such  teeth.  Modern  practice  is 


134    Insomnia  and  Nerve  Strain 

to  fill  dead  teeth  to  the  end  of  the  roots, 
as  nearly  as  may  be. 

To  estimate  the  proportion  of  success 
and  failure  of  this  procedure  it  will  be 
necessary  to  consider  in  brief  the  course 
of  events  in  these  cases.  The  process  is 
in  effect  a  battle  between  the  germs  and 
the  blood.  The  germs,  practically  always 
present  in  spite  of  the  greatest  care  and 
skill,  march  down  the  hollow  of  the  tooth 
by  multiplication,  often  requiring  sev- 
eral years  to  cover  the  distance  to  the  end. 
Once  out  of  the  opening  and  in  the  jaw- 
bone they  are  like  a  squad  of  soldiers  with 
their  backs  against  a  wall,  the  forces  of 
serum  or  white  blood  cell  can  only  attack 
in  front,  with  an  effectiveness  dimin- 
ished by  half,  and  even  if  successful  for 
a  time  more  germs  are  always  lurking 
in  absolute  safety  in  the  dead  tissue  of 
the  tooth. 

If  to  prevent  this  condition  filling  ma- 
terial is  pushed  to  the  end  of  the  root  and 
a  little  of  it  forced  through  into  the  jaw, 
an  irritant  is  in  contact  with  the  tissues, 
and  in  most  cases  germs  accompany  it. 


Appendix  135 

If,  on  the  other  hand,  it  falls  a  thousandth 
of  an  inch  short  of  the  opening,  the  tiny 
germs  find  ample  space  for  lodgment. 

A  man  is  as  old  as  his  arteries,  and  his 
arteries  are  approximately  as  old  as  the 
combined  action  of  suppurative  and 
other  toxins  has  made  them  in  the  preced- 
ing years.  Oral  sepsis  is  not  all  super- 
ficial. Its  most  important  location  is 
usually  deep  in  the  jaws.  In  probably 
no  other  part  of  the  body  can  purely 
irritative  lesions  be  studied  in  contrast 
with  suppuration  and  toxemia  and  the 
symptoms  of  each  condition  followed 
with  accuracy.  Impactions  result  in  pure 
irritation,  dental  caries  in  irritation  with 
a  minimum  of  toxemia;  abscesses  begin 
in  irritation,  and  result  when  large  and 
multiple  in  profound  chronic  intoxication. 

The  brilliant  and  rapidly  developing 
technique  of  dentistry  has  as  its  object 
the  preservation  of  the  teeth  for  the 
natural  mechanics  of  mastication.  "  Ne 
Varrachez  pas"  is  the  dental  watch-word 


136    Insomnia  and  Nerve  Strain 

in  this  country  even  more  than  in  France. 
The  preservation  of  dead  teeth  is  of 
doubtful  value.  Suppuration  may  occur 
about  well  filled  teeth,  and  even  about 
teeth  that  are  unfilled  and  undecayed.  It 
is  almost  inevitable  about  bad  teeth,  and 
the  one  sure  method  of  treatment  is 
extraction,  which  may,  however,  in  many 
cases  be  reserved  until  after  the  trial  of 
conservative  measures. 

The  ominous  conjunction  of  multiple 
abscesses  with  the  triad  of  cardiac, 
renal,  and  vascular  disease  is  one  that  has 
been  casually  noted  in  several  of  the 
cases  reported  in  this  series  and  some 
others.  To  exclude  suppuration  as  a 
causative  factor  in  these  cases  skiagraphs 
are  absolutely  necessary. 

Many  other  lesions  are  potent  in 
causing  irritation.  Fillings  which  en- 
croach on  the  soft  tissues  or  bone  are 
often  revealed  by  the  skiagraphs  and  so 
remedied.  I  am  unable  as  yet  to  give 
any  estimate  of  the  importance  of  pulp 


Appendix  137 

nodules.  It  is  only  possible  for  me  at 
present  to  make  the  broad  general  state- 
ment that  irritation  and  septic  poisoning 
should  be  removed  in  every  case,  and 
that  local  results  of  dental  lesions  are 
trifling  in  comparison  with  their  pro- 
founder  effect  on  general  health. 

In  studying  skiagraphs  the  original 
negative  should  always  be  employed. 
Much  detail  is  lost  in  printing.  The  best 
results  in  the  diagnosis  and  treatment 
of  cases  dependent  wholly  or  in  part  on 
dental  disease  are  to  be  obtained  only  by 
the  co-operation  of  the  physician  and  the 
dentist.  Skilful  reading  of  skiagraphs 
on  the  part  of  the  physician  is  absolutely 
necessary;  all  of  the  teeth  in  both  jaws 
must  be  shown  to  the  ends  of  the  roots. 

I  wish  to  express  my  thanks  to  Dr.  C. 
H.  Clark,  of  the  Cleveland  State  Hospital, 
Dr.  H.  C.  Eyman,  of  the  Massillon  State 
Hospital,  and  Dr.  George  Stockton,  of 
the  Columbus  State  Hospital,  for  their 
courtesy  in  allowing  me  to  observe  the 
patients  under  their  care. 


138  Insomnia  and  Nerve  Strain 

I  am  indebted  to  Doctors  J.  F.  Stephan, 
E.  B.  Lodge,  and  J.  W.  Van  Doom  for 
much  aid  in  dental  matters.  It  need 
hardly  be  added  that  the  writer  is  alone 
responsible  for  the  opinions  here  set  down. 


THE  TECHNIQUE  OF  DENTAL 
SKIAGRAPHY 

BY  DR.  E.  BALLARD  LODGE,  CLEVELAND 

PHE  peculiar  anatomical  conditions  of 
the  maxillae  and  the  teeth  render  their 
examination  by  Roentgen  rays  satisfac- 
tory only  when  skiagraphs  are  taken  by 
placing  the  sensitive  film  or  plate  within 
the  oral  cavity.  A  skiagraph  taken  through 
the  maxilla  or  the  mandible  with  the  plate 
placed  opposite  causes  not  only  a  distor- 
tion and  lack  of  fine  definition  but  also  a 
duplication  of  the  shadows  which  render 
the  resulting  picture  vague  and  difficult 
of  interpretation.  The  writer's  method 
for  obtaining  skiagraphs  of  the  teeth  and 
adjacent  tissue  is  to  make  use  of  small 
plates  or  films,  preferably  the  latter, 
protected  from  light  and  saliva  as  follows. 
Two  Seed's  Process  Films  i  J  x  ij  inches 
are  wrapped  in  two  folds  of  photographer's 
139 


140   Insomnia  and  Nerve  Strain 

black  paper.  The  ends  are  turned  to  the 
side  opposite  the  chemical  side  of  the 
films  and  pasted  down  with  a  piece  of 
suitable  paper.  The  films  may  now  be 
taken  to  the  light  without  danger  of 
fogging.  Next  enclose  the  envelope  in  a 
small  aseptic  napkin  such  as  is  made  for 
dental  use,  six  inches  square.  This  is  to 
prevent  the  corners  of  the  envelope  from 
irritating  the  tissues.  The  ends  are 
folded  away  from  the  chemical  side  of  the 
film.  Having  done  this,  wrap  the  whole 
in  a  small  piece  of  dental  rubber  dam 
five  inches  by  two  inches.  This  is 
stretched  and  holds  to  the  corners  of  the 
package  if  tightly  drawn.  The  rubber  is 
particularly  necessary  in  taking  lower 
teeth  to  protect  the  films  from  moisture. 
The  package  is  now  placed  within  the 
mouth  and  in  contact  with  the  lingual 
surfaces  of  the  teeth,  the  patient  being 
directed  to  hold  it  in  position  by  the 
finger.  It  is  important  to  place  the 
edge  of  the  film  parallel  to  the  occlusal 
or  incisal  alignment,  and  the  chemical 
side  toward  the  ray. 


Technique  of  Dental  Skiagraphy  141 

The  adjustment  of  the  tube  varies  for 
different  parts  of  the  jaws.  The  ray 
should  always  strike  the  film  or  plate 
at  right  angles  to  a  plane  midway  be- 
tween the  film  and  the  teeth.  In  the 
molar  and  bicuspid  region  of  the  upper 
maxilla,  the  elevation  of  the  tube  with 
reference  to  the  teeth  should  be  from 
forty-five  to  fifty  degrees  above  the  hori- 
zontal. In  the  incisor  or  cuspid  region, 
the  tube  may  be  somewhat  higher  than 
this. 

In  the  case  of  the  lower  molars  and 
bicuspids,  the  ray  should  be  horizontal 
so  that  it  will  strike  the  plate  at  right 
angles,  because  in  this  instance  it  is 
possible  to  place  the  film  or  plate  parallel 
with  the  long  axes  of  the  teeth.  In  case 
the  film  is  not  held  in  a  vertical  position 
but  inclines  away  from  the  teeth  at 
its  lower  edge,  it  then  becomes  necessary 
to  lower  the  source  of  the  ray  or  to  elevate 
the  patient  so  that  the  ray  emanates  from 
a  point  a  few  degrees  below  the  horizontal, 
to  compensate  for  this  deviation  from  a 
parallel  position. 


142    Insomnia  and  Nerve  Strain 

With  the  lower  incisors  it  becomes 
necessary  to  direct  the  ray  thirty  to 
forty-five  degrees  upward  in  order  to  get 
a  skiagraph  that  will  not  be  greatly 
distorted.  This  is  because  the  film 
cannot  be  placed  with  its  lower  edge 
close  to  the  teeth.  The  anode  is  placed 
at  an  average  distance  of  ten  inches  from 
the  teeth  and  the  time  of  exposure  is 
about  seven  seconds. 

Unless  the  angle  of  incidence  of  the  ray 
is  carefully  calculated,  there  is  apt  to  be 
either  a  foreshortening  or  an  elongation 
of  the  shadow. 


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